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.

Answer and Explanation

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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Correct Answer is A

Explanation

A) Correct - Encouraging the client to void often is important, as a full bladder can increase discomfort and interfere with labor progress.
B) Incorrect- Remaining awake between contractions might not directly address pain management strategies.
C) Incorrect- Position changes can help with pain management, so minimizing them would not be appropriate.
D) Incorrect- The presence of a support person is often encouraged during labor, and there is no need to limit their time in the room.

A. "I should elevate my baby's head on a cushion when she is sleeping" B. "I should replace the batteries in my smoke detector twice per year." C. "I should set my hot water heater to 130 degrees Fahrenheit. D. "I should use baby powder with each diaper change

Correct Answer is B

Explanation

A) Incorrect- Elevating a baby's head with a cushion during sleep is not recommended, as it can increase the risk of sudden infant death syndrome (SIDS) and obstructed breathing.
B) Correct - "I should replace the batteries in my smoke detector twice per year." Regularly replacing smoke detector batteries helps ensure they function properly in case of a fire emergency.
C) Incorrect- Setting the hot water heater to 130°F (54.4°C) is too hot and can cause scalding burns. The recommended temperature is 120°F (48.9°C) or lower.
D) Incorrect- Baby powder is not recommended for use with diaper changes, as it can be inhaled by the baby and lead to respiratory issues.

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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?

Nursing Test Bank

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Correct Answer is B

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