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
Choice A Reason:
"The nurse will carry your newborn to the nursery for procedures. "This statement is inappropriate. In current practice, there is an emphasis on family-centered care, and parents are often encouraged to be involved in the care of their newborns, including accompanying them for procedures whenever possible.
Choice B Reason:
"We will document the relationship of visitors in your medical record." This statement is inappropriate. While it is important to monitor and document visitors, the primary focus here is on healthcare staff and their identification.
Choice C Reason:
"Your baby will stay in the nursery while you are asleep." This statement is inappropriate. Promoting rooming-in and encouraging parental involvement in newborn care is a common practice to support bonding and breastfeeding, so this statement may not align with current best practices.
Choice D Reason:
"Staff members who take care of your baby will be wearing a photo identification badge." This statement reassures the client that the healthcare providers involved in the care of the newborn will have proper identification, enhancing security and ensuring that authorized personnel are handling the infant.
Correct Answer is A
Explanation
Choice A Reason:
Applying sacral counterpressure is appropriate. In the right occiput posterior position, the fetal head is positioned towards the mother's back, leading to increased pressure on the sacral are
A. Applying sacral counterpressure can help alleviate back pain during contractions.
Choice B Reason:
Performing transcutaneous electrical nerve stimulation (TENS) is inappropriate. While TENS can be used for pain relief in labor, applying sacral counterpressure is a more specific intervention for back pain related to fetal positioning.
Choice C Reason:
Initiating slow-paced breathing is inappropriate. While slow-paced breathing is a coping mechanism during contractions, it may not specifically address the back pain associated with the fetus in the right occiput posterior position.
Choice D Reason:
Assisting with biofeedback is inappropriate. Biofeedback is not a standard intervention for managing back pain during labor, especially in the context of fetal positioning. Sacral counterpressure is a more direct approach for this situation.
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