A nurse is assisting in the care of a client who is admitted for complications associated with intrauterine fetal demise and becomes unresponsive.
Which of the following actions should the nurse take first?
Obtain a set of vital signs.
Assess vaginal bleeding.
Call the rapid response team.
Notify the provider.
The Correct Answer is C
Choice A rationale
Obtaining a set of vital signs is important but not the first action. Assessing responsiveness and activating emergency response takes precedence to ensure prompt intervention.
Choice B rationale
Assessing vaginal bleeding is necessary, but it should follow immediate life-saving actions like calling the rapid response team.
Choice C rationale
Calling the rapid response team should be the first action as it mobilizes a team of healthcare professionals to provide immediate advanced care, which is crucial in an unresponsive patient.
Choice D rationale
Notifying the provider is essential, but it should be done after the rapid response team is activated to ensure timely intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Painless, bright red vaginal bleeding at 36 weeks gestation is a classic sign of placenta previa, where the placenta is abnormally implanted in the lower uterine segment, covering the cervix, and causing bleeding without pain.
Choice B rationale
Threatened abortion is characterized by vaginal bleeding before 20 weeks of gestation with or without abdominal pain. At 36 weeks, the term would be inappropriate, and the symptoms do not match.
Choice C rationale
Abruptio placentae involves painful vaginal bleeding due to premature placental separation. The presence of pain differentiates it from placenta previa.
Choice D rationale
Preterm labor may present with contractions, cervical changes, and possible bleeding, but the key feature distinguishing it from placenta previa is the presence of uterine contractions and pain, which are absent in this scenario.
Correct Answer is B
Explanation
Choice A rationale
Cervical dilation is a source of visceral pain during labor due to the stretching and opening of the cervix, and it is not incorrect information.
Choice B rationale
Stretching of the pelvic muscles is incorrect because visceral pain during labor is typically associated with internal organs and not the stretching of pelvic muscles, which is more somatic pain.
Choice C rationale
Nerve stimulation is a cause of visceral pain as labor pain is transmitted through the nerves to the spinal cord and brain.
Choice D rationale
Uterine contractions are a major source of visceral pain during labor as they involve the powerful and rhythmic tightening and relaxing of the uterine muscles.
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