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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Nägele's rule is a method used to estimate the expected date of delivery (EDD) for a pregnant woman. To use Nägele's rule, you start with the first day of the last menstrual period (LMP), add one year, subtract three months, and add seven days.

In this case:

LMP: November 27th

Add one year: November 27th of the following year

Subtract three months: August 27th

Add seven days: September 3rd

Therefore, according to Nägele's rule, the expected date of birth is September 3rd

A. "it sounds like you are feeling sad that things didn't go as planned. B. "Maybe next time you can have a vaginal delivery" C. "At least you know you have a healthy baby D. You can resume sexual relations sooner than if you had delivered vaginally

Correct Answer is A

Explanation

The correct answer is A. "It sounds like you are feeling sad that things didn't go as planned."

A. This response reflects empathy and acknowledges the client's feelings without judgment. It validates the client's emotions and provides an opportunity for her to express her feelings further.

B. "Maybe next time you can have a vaginal delivery" is not an appropriate response as it assumes that the client will or should have another pregnancy and may have a vaginal delivery. It is more important to address the current emotions and experience.

C. "At least you know you have a healthy baby" dismisses the client's feelings of disappointment. While the health of the baby is important, it's essential to acknowledge and validate the client's emotional experience.

D. "You can resume sexual relations sooner than if you had delivered vaginally" is not relevant to the client's expressed disappointment about the mode of delivery. It may not be an appropriate or comforting statement given the context.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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