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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The practical nurse (PN) should recognize that the client who is 2-weeks postpartum and presents with feelings of irritability, severe mood swings, and an irrational sense of her ability to keep her infant safe may be exhibiting symptoms of postpartum psychosis. Postpartum psychosis is a rare but serious condition that can develop after childbirth and is characterized by symptoms such as delusions, hallucinations, and severe mood swings. The client's belief that her infant is going to die and that there is nothing she can do to save her baby may indicate the presence of delusions. The PN should report these symptoms to the appropriate healthcare provider for further assessment and intervention.
Correct Answer is B
Explanation
Repeated visits to multiple emergency departments for various injuries or complaints can be a red flag for possible child abuse. The other options may indicate other issues or concerns, but they do not provide as much reason to suspect child abuse as the history of repeated visits to different emergency departments. It is important for healthcare providers to remain vigilant for signs of child abuse and to report any suspicions to the appropriate authorities.
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