A nurse is assisting in the care of a client who is in labor and whose membranes ruptured 6 hr ago. Which of the following is an appropriate nursing intervention for this client?
Monitor for infection.
Position the client supine.
Obtain consent for a cesarean birth.
Prepare for a forceps delivery.
The Correct Answer is A
A) Correct - Monitoring for infection is an appropriate nursing intervention for a client whose membranes have ruptured, as there is an increased risk of infection after the amniotic sac has ruptured for an extended period.
B) Incorrect- Positioning the client supine is not generally recommended for a client in labor, especially if the client's membranes have ruptured.
C) Incorrect- Obtaining consent for a cesarean birth is not indicated solely based on the information provided.
D) Incorrect- Preparing for a forceps delivery is not indicated solely based on the information provided.
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Related Questions
Correct Answer is B
Explanation
A) Incorrect- While placing the baby in the bassinet in the room is a good practice, it may not be sufficient to prevent abduction.
B) Correct - Ensuring that anyone caring for or transporting the baby is wearing an identification badge helps confirm their authorized status to handle the baby.
C) Incorrect- Carrying the baby in the arms is a safe practice, but it doesn't specifically address preventing abduction.
D) Incorrect- Placing the identification band in the bassinet drawer is not a recommended practice, as it can potentially lead to confusion or misidentification.
Correct Answer is A
Explanation
A) Correct - Dysuria (painful urination) could indicate a urinary tract infection (UTI) which, if left untreated, can lead to complications during pregnancy. It requires prompt evaluation and treatment.
B) Incorrect- Varicose veins and gingivitis are common discomforts during pregnancy, but they are not typically considered urgent issues.
C) Incorrect- Gingivitis (inflammation of the gums) is common during pregnancy and should be addressed, but it is not as urgent as a potential UTI.
D) Incorrect- Leukorrhea (white vaginal discharge) is a common occurrence during pregnancy and is usually not a priority concern unless it's accompanied by other symptoms.
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