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 A
Explanation
Rationale:
A. Provide humidification of the room air: Xerostomia, or dry mouth, often results from radiation therapy to the head and neck region. Humidifying room air adds moisture to the environment, helping relieve oral dryness and improving comfort, especially during sleep.
B. Suggest rinsing his mouth with an alcohol-based mouth wash: Alcohol-based mouthwashes can worsen oral dryness and irritate mucosal tissues, making xerostomia more uncomfortable. Clients should instead use alcohol-free or moisturizing rinses.
C. Instruct the client on the use of esophageal speech: Esophageal speech is a communication method taught to clients after laryngectomy, not for xerostomia. It does not address dry mouth and is unrelated to the effects of mandibular radiation.
D. Offer the client saltine crackers between meals: Saltine crackers are dry and salty, which can exacerbate oral dryness and discomfort. Clients with xerostomia benefit more from moist, soft foods and frequent sips of water.
Correct Answer is B
Explanation
Rationale:
A. Use Leopold maneuvers to determine the fetal position: Leopold maneuvers are not appropriate as an immediate response to sudden nausea. The priority is to relieve the symptom, which may be related to positional compression of major blood vessels.
B. Position the client on her side: At 36 weeks gestation, the gravid uterus can compress the inferior vena cava when lying supine, leading to supine hypotensive syndrome. Symptoms like nausea, dizziness, and hypotension can occur. Side-lying positioning relieves the pressure and restores venous return and cardiac output.
C. Administer propranolol IV to the client: Propranolol is not indicated for treating pregnancy-related nausea or hypotension. Using it without a cardiovascular diagnosis would be inappropriate and could worsen hypotensive symptoms.
D. Ask the client to increase her daily calcium intake: While calcium is essential in pregnancy, especially for fetal bone development, increasing calcium intake has no immediate impact on sudden nausea or circulatory symptoms linked to maternal positioning.
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