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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?

A.

Initiate fundal massage.

B.

Apply a fetal heart rate monitor.

C.

Insert an indwelling urinary catheter.

D.

Initiate an oxytocin IV infusion.

Answer and Explanation

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.


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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}

Explanation

Rationale:

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Correct Answer is D

Explanation

Rationale:

A. ½ cup apple juice: Apple juice contains a relatively low amount of potassium, making it a poor choice for correcting hypokalemia. It typically provides less than 150 mg per half-cup serving.

B. ½ cup steamed cauliflower: Cauliflower is low in potassium compared to other vegetables. While healthy, it does not significantly contribute to raising potassium levels in the body.

C. 1 cup boiled white rice: White rice has minimal potassium content, especially when boiled. It is not effective in increasing potassium and is typically suitable for clients requiring low-potassium diets.

D. 1 cup cantaloupe: Cantaloupe is high in potassium, offering around 400–500 mg per cup. It is among the best fruit sources for replenishing potassium and is appropriate for clients with mild hypokalemia.

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