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 B

Explanation

A. Decreased heart rate: This is not typically an indication of pain in a newborn. Pain can often lead to an increased heart rate as the body responds to stress or discomfort.

B. Chin quivering: This is a common sign of pain in newborns. When infants experience pain, they may exhibit facial expressions such as quivering of the chin, furrowing of the brow, or grimacing.

C. Pinpoint pupils: Pinpoint pupils are not a typical sign of pain in a newborn. This may be associated with certain medications or conditions affecting the nervous system, but it is not a direct indicator of pain.

D. Slowed respirations: While pain can sometimes cause changes in respiratory patterns, slowed respirations alone may not be a reliable indicator of pain in a newborn. Other signs, such as facial expressions or crying, are often more indicative of pain.

A. "You should replace the diaphragm every 5 years." B. "You should leave the diaphragm in place for at least 6 hours after intercourse." C. "You should use an oil-based product as a lubricant when inserting the diaphragm." D. "You should insert the diaphragm when your bladder is full."

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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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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