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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct- Amoxicillin is a safe and effective antibiotic for treating chlamydia infection in pregnant women.
B) Incorrect - Tetracycline and related antibiotics are often used to treat chlamydia, but they are contraindicated during pregnancy due to potential effects on fetal tooth and bone development. is contraindicated in pregnancy because it can cause fetal tooth discoloration and bone deformities.
C) Incorrect- Metronidazole is used for treating bacterial vaginosis and certain other infections, but it is not the first-line treatment for chlamydia.
D) Incorrect- Acyclovir is used to treat herpes simplex virus infections, not chlamydia.
Correct Answer is D
Explanation
Rationale:
A) Incorrect - Applying oxygen is not the priority action in the case of excessive vaginal bleeding and a boggy uterus. Oxygen therapy would be appropriate if there were signs of respiratory distress or decreased oxygen saturation, but it does not directly address the primary concern of uterine atony and bleeding.
B) Incorrect - Administering methylergonovine might be appropriate, but the priority is to address the uterine atony with fundal massage first. Fundal massage helps stimulate uterine contractions and control bleeding, which is crucial in this scenario.
C) Incorrect - Encouraging the client to empty her bladder is important, but it is not the first action to take in the case of excessive bleeding and uterine atony. Immediate intervention to control the bleeding takes precedence.
D) Correct - Initiating fundal massage is the priority action in this situation. A boggy uterus with excessive vaginal bleeding indicates uterine atony, which is a potentially life-threatening condition requiring immediate intervention to prevent further bleeding.
Fundal massage helps the uterus contract and control bleeding. Addressing uterine atony is critical to prevent further hemorrhage and stabilize the client's condition.
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