A nurse is assisting with the care of a client who presents to a labor and delivery unit with rapidly progressing labor. Which of the following actions is the priority for the nurse to take?
Supporting the infant during the birth.
Preventing the perineum from tearing.
Cutting the umbilical cord.
Promoting delivery of the placenta.
The Correct Answer is A
Choice A rationale:
Supporting the infant during birth. The priority for the nurse in this situation is to ensure the safe delivery of the baby. By supporting the infant during birth, the nurse can help ensure that the baby is delivered safely and efficiently. This involves assisting the mother in pushing and guiding the baby's head and body as it emerges from the birth canal. The nurse should also be ready to catch the baby and provide immediate care, such as drying and stimulating the baby to breathe if necessary.
Choice B rationale
Preventing the perineum from tearing. While preventing perineal tearing is important, it is not the top priority in this rapidly progressing labor scenario. The immediate concern is the safe delivery of the baby, and if perineal tearing does occur, it can be addressed after the birth.
Choice C rationale
Cutting the umbilical cord. This action is necessary but not the top priority. After the baby is delivered, the nurse should clamp and cut the umbilical cord to separate the baby from the placenta. However, this can wait until the baby is fully delivered and breathing on their own.
Choice D rationale
Promoting delivery of the placenta. Again, while delivering the placenta is important to prevent postpartum haemorrhage, it is not the priority in this scenario. The nurse's immediate focus should be on supporting the infant's delivery and ensuring the baby's well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The client's statement, "I need to schedule the test when the baby is usually active,”. is accurate and demonstrates a good understanding of the nonstress test (NST). The NST is typically performed to assess the baby's heart rate and movements when they are active, which provides better insights into the baby's well-being.
Choice B rationale:
The client's statement, "The baby's heart rate will be monitored during the test,”. is correct and indicates a solid grasp of the purpose of the NST. During the test, the baby's heart rate is continuously monitored to assess their overall well-being and any signs of distress.
Choice C rationale:
This is the correct answer. The client's statement, "I will have to lie on my back during the test,”. indicates a need for further teaching. In an NST, pregnant individuals are usually asked to lie on their left side, not on their back. The left lateral position enhances blood flow to the placenta and the baby, making it the preferred position for this test.
Choice D rationale:
The client's statement, "I will be able to go to the bathroom during the test as necessary,”. is accurate and demonstrates a good understanding of the NST procedure. Unlike some other prenatal tests, NST allows pregnant individuals to change positions, including using the bathroom if needed, to ensure their comfort during the monitoring process.
Correct Answer is D
Explanation
Choice D rationale:
The correct answer is Choice D. The biophysical profile is a prenatal test used to assess fetal well-being in the third trimester of pregnancy. It is not used to determine the estimated date of birth (Choice A), as that is typically calculated based on the first day of the last menstrual period and confirmed or adjusted by early ultrasounds.
The test also does not require the client to be NPO (nothing by mouth) for 8 hours prior to the test (Choice B). This restriction is commonly associated with certain medical procedures, but it is not applicable to the biophysical profile.
Furthermore, there is no need to initiate an IV (intravenous line) before the biophysical profile (Choice C). The test is non-invasive and involves the use of ultrasound and fetal heart rate monitoring. The biophysical profile assesses several fetal parameters, such as fetal movement, fetal tone, fetal breathing movements, amniotic fluid volume, and the fetal heart rate. These parameters help evaluate the well-being and health of the baby. The test is often recommended in cases of high-risk pregnancies, decreased fetal movement, or other conditions that may warrant closer monitoring of the baby's condition. By knowing that the biophysical profile predicts fetal well-being in the third trimester, the nurse can provide accurate information to the client, reassuring them about the health of their baby and explaining the importance of the test in ensuring a safe delivery and healthy outcome.
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