A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
Determine respiratory function.
Increase the TV fluid rate.
Access emergency medications from cart
Collect a maternal blood sample for coagulopathy studies
The Correct Answer is A
The correct answer is A.
A. Determine respiratory function: The priority is to assess the client's airway, breathing, and circulation (ABCs). If the client becomes unresponsive, the nurse should quickly assess whether the airway is clear, check for breathing, and determine if there is a pulse. This initial assessment is crucial for identifying and addressing any immediate life-threatening issues.
B. Increase the TV fluid rate: While fluid administration may be necessary in certain situations, it is not the first priority when a client becomes unresponsive. Assessing respiratory function and circulation takes precedence to address immediate life-threatening concerns.
C. Access emergency medications from the cart: Accessing emergency medications may be necessary, but it should occur after the initial assessment of the client's airway, breathing, and circulation. Administering medications without first assessing the client's ABCs may delay appropriate interventions.
D. Collect a maternal blood sample for coagulopathy studies: This action is important for assessing coagulation status, but it is not the first priority when a client becomes unresponsive. The immediate focus should be on ensuring the client has a patent airway, is breathing, and has a pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Resting tone of 15 mmHg:A resting tone of 15 mmHg is generally acceptable and indicates normal uterine resting pressure, which should be between 5 and 20 mmHg.
B. Frequency of every two minutes. A frequency of every two minutes can be acceptable during labor, especially if the contractions are not too long or intense. The key consideration is the duration and intensity of the contractions.
C. Intensity of 60 to 90 mmHg: This intensity is typically acceptable for labor induction and signifies effective contractions. There’s no indication to stop oxytocin based solely on this intensity range.
D. Duration of 90 to 120 seconds:A contraction lasting 90 to 120 seconds is concerning and indicates potential uterine hyperstimulation, warranting the discontinuation of oxytocin to protect both the mother and fetus from adverse effects.
Correct Answer is D
Explanation
A. The cervix being effaced is not represented by the -1 notation in a vaginal examination. Effacement is usually expressed as a percentage.
B. The -1 notation does not represent cervical dilation. Dilation is measured in centimeters.
C. The presenting part being 1 cm below the ischial spines is not correct. In the station system, if the presenting part is above the ischial spines, it is represented by a negative number. A -1 station indicates that the presenting part is 1 cm above the ischial spines.
D. The presenting part is 1 cm above the ischial spines is the correct interpretation.
In the station system, if the presenting part is above the ischial spines, it is represented by a negative number. A -1 station indicates that the presenting part is 1 cm above the ischial spines.
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