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 B
Explanation
A. Encouraging the client to proceed with the surgery may dismiss their valid fears and does not address the underlying emotional concerns. It is important to acknowledge the client’s feelings rather than pressuring them to continue.
B. Notifying the charge nurse of the client’s concerns ensures that the client’s emotional state and any potential issues with informed consent are addressed appropriately. The charge nurse can facilitate further discussion with the surgical team to ensure the client’s concerns are managed and that the consent remains valid.
C. Documenting the client’s concerns is important for legal and clinical reasons, but it does not address the client’s immediate emotional needs or resolve their fears. The priority is to ensure the client’s concerns are addressed and escalated if necessary.
D. Reminding the client that consent has already been obtained does not validate their current emotional concerns and can be dismissive. The focus should be on addressing the client’s anxiety and exploring their concerns.
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"E","dropdown-group-3":"D"}
Explanation
- Dark Room Lighting
Consistent with Elder Mistreatment: A dark, uninviting environment can indicate neglect or lack of proper care. It may reflect poor living conditions or neglect of the client's environment, which can be a sign of mistreatment. - Malnutrition
Consistent with Elder Mistreatment: The client’s low weight (98 lb) relative to her height (5 ft 4 in) suggests potential malnutrition. Malnutrition can be a sign of neglect, as the client might not be receiving adequate food or nutrition, which is a form of mistreatment. - Pressure Injuries
Consistent with Elder Mistreatment: Although the pressure injuries have closed, the presence of Stage II pressure ulcers in the past indicates a lack of proper care and attention to the client’s needs. Pressure ulcers are a common sign of neglect in care settings.
Not Consistent with Elder Mistreatment
- Poor Hygiene
Not Consistent: The client appears clean and healthy with no issues in skin condition or oral hygiene, so this is not a sign of mistreatment. - Bilateral Leg Edema
Not Consistent: While edema might be a concern in heart failure management, it is not specifically indicative of elder mistreatment. - Short Term Memory Loss
Not Consistent: Short-term memory loss is not necessarily a sign of mistreatment; it could be related to aging or medical conditions.
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