A client who is multiparous at 38-weeks gestation is admitted to labor and delivery with contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the practical nurse (PN) hears a baby crying. Which action should the PN take first?
Turn on the infant warmer.
Push the call light for help.
Notify a healthcare provider.
Inspect the client's perineum.
The Correct Answer is B
A. Turning on the infant warmer is a necessary step but comes after confirming that the infant is actually being born. The immediate priority is to assess the situation to ensure the health and safety of both the mother and baby.
B. Pushing the call light alerts other healthcare professionals that immediate assistance is needed. Given that the baby is crying, it suggests that the birth may have occurred unexpectedly, and help is required to manage the situation safely.
C. Notifying a healthcare provider is essential, but the PN should first verify the situation to provide accurate information and context for the healthcare provider's arrival.
D. Inspecting the perineum is important to assess for any complications or to check if delivery has occurred. However, this action should follow ensuring that help is called and that the environment is safe for both mother and baby. The primary focus should be on ensuring that assistance is on the way before performing an assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The submandibular lymph nodes are located beneath the lower jaw, in the area where the jawbone meets the neck. This is the correct location to palpate for enlargement of these lymph nodes.
B. The temporal bone is located on the side of the head, not relevant to the location of the submandibular lymph nodes. Palpation for these nodes occurs beneath the lower jaw, not near the temporal bone.
C. Lateral to the trachea refers to the location of other lymph nodes such as the anterior cervical or supraclavicular nodes, not the submandibular nodes. Submandibular nodes are specifically beneath the jaw.
D. Above the upper jaw does not correspond to the location of the submandibular lymph nodes. These nodes are palpated beneath the lower jaw, making this option incorrect.
Correct Answer is A,B,C,D
Explanation
A. Exposing the left side of the chest is the first step to access the area where the apical pulse is assessed. This step ensures that the nurse has clear access to the chest for auscultation.
B. Locating the point of maximal impulse (PMI) is the next step once the chest is exposed. The PMI, typically located at the 5th intercostal space at the midclavicular line, is where the heart’s apex is closest to the chest wall.
C. Positioning the diaphragm of the stethoscope on the PMI is the step where the actual auscultation begins. The diaphragm is used to listen for heart sounds.
D. Listening for heart sounds at the PMI is the final step to assess the apical heart rate. This step completes the assessment by allowing the PN to count the heart rate and evaluate the rhythm.
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