A nurse is caring for a client who is at 38 weeks of gestation, is in active labor, and has ruptured membranes. Which of the following actions should the nurse take?
Initiate fundal massage.
Apply a fetal heart rate monitor.
Insert an indwelling urinary catheter.
Initiate an oxytocin IV infusion.
The Correct Answer is B
Rationale:
A. Initiate fundal massage: Fundal massage is performed after delivery to prevent or manage uterine atony and postpartum hemorrhage. It is not appropriate during active labor, especially before the birth of the fetus.
B. Apply a fetal heart rate monitor: After rupture of membranes, there is an increased risk of umbilical cord prolapse or fetal distress. Continuous fetal monitoring is essential to assess fetal well-being and detect complications promptly.
C. Insert an indwelling urinary catheter: While catheterization may be done later, especially before epidural placement or cesarean delivery, it is not the most urgent action. It does not address immediate risks associated with ruptured membranes.
D. Initiate an oxytocin IV infusion: Oxytocin is used to augment or induce labor, but should not be started without first assessing fetal status. Fetal monitoring is necessary to establish a baseline before initiating uterotonic agents.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Place the client in a supine position: The supine position may impair respiratory function and increase discomfort, especially in terminal clients who may experience dyspnea. A semi-Fowler’s or side-lying position is often preferred for comfort and easier breathing.
B. Remind the client to eat scheduled meals daily: For clients nearing end of life, appetite naturally decreases, and forcing meals can cause distress. Care should focus on comfort, allowing the client to eat only if and when they desire rather than adhering to structured meal times.
C. Speak in a loud tone when addressing the client: Loud speech is not appropriate unless the client has documented hearing impairment. A calm, soft tone is more comforting and respectful, especially in the emotionally sensitive context of end-of-life care.
D. Offer the client a blanket to keep warm: Clients nearing the end of life often experience poor circulation and may feel cold. Providing a blanket is a comfort-focused, non-invasive intervention that promotes warmth and dignity during this phase.
Correct Answer is D
Explanation
Rationale:
A. Protamine: Protamine is used to reverse the effects of heparin, particularly in cases of heparin overdose or to stop excessive bleeding. It does not treat allergic reactions like urticaria.
B. Naloxone: Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression or overdose. It has no effect on histamine-mediated symptoms such as urticaria.
C. Hydralazine: Hydralazine is an antihypertensive medication that lowers blood pressure by relaxing arterial smooth muscle. It is not appropriate for managing allergic skin reactions.
D. Diphenhydramine: Diphenhydramine is an antihistamine that blocks histamine receptors, making it effective for treating allergic reactions such as urticaria (hives). It reduces itching, swelling, and redness caused by histamine release.
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