A nurse is assisting with the care of a client who is in active labor. Which of the following data is the priority
for the nurse to collect following an amniotomy?
Amniotic fluid color
The client's temperature
Frequency of contractions
Fetal heart rate
The Correct Answer is D
The priority data for the nurse to collect following an amniotomy is the fetal heart rate. This is an important nursing intervention to assess fetal well-being and identify any potential complications.
a) Assessing the color of the amniotic fluid is important, but it is not the highest priority.
b) Monitoring the client's temperature is important, but it is not the highest priority.
c) Assessing the frequency of contractions is important, but it is not the highest priority.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
d. Remove the IV catheter.
Explanation:
The correct answer is d. Remove the IV catheter.
If the nurse realizes that the incorrect IV solution is infusing, it is essential to take prompt action to prevent harm to the client. Removing the IV catheter is the appropriate course of action to stop the infusion of the incorrect solution.
Option a, completing an incident report, may be necessary after the immediate situation has been addressed, but it should not be the nurse's first action. The priority is to stop the incorrect solution from infusing.
Option b, allowing the current solution to finish infusing and then changing the bag, is not the correct action. Continuing the infusion of the incorrect solution can potentially harm the client and must be stopped immediately.
Option c, documenting that an error occurred in the client's medical record, is important, but it should be done after taking immediate action to stop the incorrect solution from infusing. Documentation should include the details of the incident, any actions taken, and the client's response.
By promptly removing the IV catheter, the nurse stops the infusion of the incorrect solution and prevents further harm to the client. Afterward, the nurse should assess the client for any adverse effects, inform the appropriate healthcare providers, and follow the facility's policies and procedures for reporting incidents and documenting the error.
Correct Answer is C
Explanation
The statement by the client that indicates an understanding of the teaching is "I plan to take water aerobics classes at the gym near my house." Exercise is an important part of managing osteoarthritis, and water aerobics is a low-impact exercise that can help improve joint mobility and reduce pain.
Option ais incorrect because applying cold compresses may not be the most effective way to manage pain associated with osteoarthritis. Heat therapy is often more effective for this condition.
Option b is incorrect because limiting purine intake in the diet is recommended for clients with gout, not osteoarthritis.
Option d is incorrect because ibuprofen can be an effective pain reliever for clients with osteoarthritis.
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