A client who is a primigravida at 40 weeks gestation is contracting every 2 minutes and her cervix is 9 cm dilated and 100% effaced. The fetal heart rate is 120 beats/minute. The client is screaming and her husband is alarmed. Which intervention should the practical nurse (PN) implement?
Call the rapid response team to the bedside.
Check the time the last PRN narcotic analgesic was given.
Report to charge nurse that the client is near to delivery.
Ask the husband to leave the room for a while.
The Correct Answer is C
The practical nurse should report to the charge nurse that the client is near delivery, as the client's signs indicate that she is in the transition phase of labor and is likely to deliver soon. The PN should also assess the client's vital signs, fetal heart rate, and pain level, and prepare the delivery equipment.
The husband can be asked to provide emotional support to the client during labor.
The rapid response team may be called in case of a medical emergency, but this is not indicated based on the information given.
Checking the time, the last PRN narcotic analgesic was given is also not indicated at this point, as the client is close to delivery and may not have time for medication to take effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Flaring of the nares, or widening of the nostrils, is a sign of respiratory distress in infants. It indicates that the child is working harder to breathe. This finding should alert the practical nurse (PN) that the child with bronchiolitis is in acute respiratory distress.
A resting respiratory rate of 35 breaths/minute (B) is within the normal range for a 3-month-old infant. Bilateral bronchial breath sounds (C) and diaphragmatic respirations (D) are not specific signs of acute respiratory distress in infants.
Correct Answer is C
Explanation
Iron supplements are often recommended for pregnant women to prevent or treat anemia and to improve the iron status of both the mother and the baby ¹. During pregnancy, you need 27 milligrams of iron a day ². Iron is also found in some foods, such as meat, beans, and leafy greens ¹. So, it is recommended to increase dietary iron-rich foods.
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