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- Foul-smelling vaginal discharge might indicate infection but is not the priority over the presence of meconium-stained amniotic fluid.
B) Correct- Fetal heart rate is important to monitor, but the presence of meconium- stained amniotic fluid has higher priority. fetal heart tones 98/min, because this indicates fetal distress and requires immediate intervention.
C) Incorrect - Amniotic fluid with meconium noted could indicate fetal hypoxia or distress, but it is not always a sign of a problem and depends on other factors such as gestational age and fetal activity.
D) Incorrect- Maternal temperature elevation might indicate infection but is not the priority over assessing the condition of the amniotic fluid and the baby.
Correct Answer is C
Explanation
A) Incorrect- Leakage of fluid is possible but not a primary focus of post-procedure instructions.
B) Incorrect- Milk of magnesia is not relevant to an amniocentesis procedure.
C) Correct - Reporting uterine contractions after the procedure is important as it could indicate a potential complication, such as preterm labor.
D) Incorrect- Blood work drawn before the procedure is not typically part of the amniocentesis process.
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