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 ["2"]
Explanation
- Convert the available strength from milligrams (mg) to micrograms (mcg) to match the desired dose's unit.
Available strength = 0.025 mg/tablet
Since 1 mg = 1000 mcg,
Calculation:
Desired dose = 50 mcg.
Available strength in mcg = 0.025 mg/tablet × 1000 mcg/mg
= 25 mcg/tablet.
Calculate the number of tablets to administer.
Number of tablets = Desired dose (mcg) / Available strength (mcg/tablet)
= 50 mcg / 25 mcg/tablet
= 2 tablets.
Correct Answer is D
Explanation
Rationale:
A. "Let's discuss some weight loss strategies that might work for you.": While well-intentioned, this response shifts focus prematurely to problem-solving rather than acknowledging the client's immediate emotional distress. It can come across as dismissive of the client's feelings and reinforce stigma.
B. "Have you always felt uncomfortable being overweight?": This question delves into the client's history without first validating their current emotional state. It may seem intrusive and bypasses the opportunity to provide empathy in the moment.
C. "How long have you struggled with your weight?": This response centers on the weight issue rather than addressing the client’s expressed feelings of being stared at and judged. It risks making the client feel pathologized rather than supported.
D. “It sounds like you're saying that you feel uncomfortable around others.”: This therapeutic response reflects the client's feelings, validates their emotional experience, and encourages further expression. It helps build trust and demonstrates empathy without judgment.
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