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 A
Explanation
The correct answer is A. Variable decelerations are due to umbilical cord compression.
A. Variable decelerations are often associated with umbilical cord compression. This compression can occur when the umbilical cord is briefly compressed or squeezed, leading to transient decreases in fetal heart rate.
B. Variable decelerations are not typically a result of the administration of IV narcotic analgesics. They are more commonly associated with cord compression or other factors affecting fetal oxygenation.
C. Variable decelerations are not generally caused by uteroplacental insufficiency. Uteroplacental insufficiency is more commonly associated with late decelerations.
D. Variable decelerations are not primarily related to fetal head compression. While head compression can cause certain types of decelerations, variable decelerations are specifically associated with umbilical cord compression.
Correct Answer is B
Explanation
Choice A Reason:
"You should replace the diaphragm every 5 years." This statement is inappropriate. Diaphragms typically need replacement more frequently than every 5 years. The lifespan of a diaphragm is usually shorter, and it may need to be replaced every 1 to 2 years, depending on the material and condition.
Choice B Reason:
"You should leave the diaphragm in place for at least 6 hours after intercourse." This statement is appropriate. Leaving the diaphragm in place for at least 6 hours after intercourse helps ensure its effectiveness in preventing pregnancy. Removing it too soon may increase the risk of sperm reaching the cervix.
Choice C Reason:
"You should use an oil-based product as a lubricant when inserting the diaphragm. "This statement is inappropriate. Oil-based lubricants can damage latex diaphragms. Water-based or silicone-based lubricants are recommended instead.
Choice D Reason:
"You should insert the diaphragm when your bladder is full." This statement is inappropriate. There is no specific need to insert the diaphragm when the bladder is full. However, emptying the bladder before insertion may make the process more comfortable for the client.
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