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 B
Explanation
The correct answer is B. Place the client in the lateral position.
A. Increasing the rate of maintenance IV infusion may be necessary, but the initial action should be to address potential aortocaval compression. Repositioning the client to the lateral position helps alleviate compression on the vena cava and improves blood flow to the uterus.
B. Placing the client in the lateral position is the correct first action. Changing the client's position, particularly from a supine to a side-lying position, can relieve aortocaval compression and improve uteroplacental perfusion.
C. Elevating the client's legs is not the priority in this situation. Repositioning the client to the lateral position is more important to address potential aortocaval compression.
D. Administering oxygen using a nonrebreather mask may be indicated, but repositioning the client to the lateral position is the first action to address potential aortocaval compression. Oxygen administration can follow if necessary.
Correct Answer is D
Explanation
The correct answer is d.
A. Informing the client that the anesthetic effect will last for approximately 6 hours is not the nurse's responsibility. The anesthesia provider usually communicates this information to the client.
B. Administering a 500 mL bolus of 5% dextrose in water prior to induction is the correct action.
Although preloading with a 500–1,000 mL bolus of isotonic crystalloid (e.g., Lactated Ringer’s) is recommended to mitigate hypotension, dextrose‑containing solutions (like D5W) are not used for this preload.
C. Having the client stand at the bedside with her arms at her side is not necessary for the administration of epidural analgesia. The client is usually positioned sitting up or lying on her side during the procedure.
D. Before initiating epidural analgesia, you must establish a baseline fetal heart rate and uterine contraction pattern with at least 20–30 minutes of continuous EFM to ensure fetal well‑being and detect any decelerations or atypical patterns.
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