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.

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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Arrange for an ethics committee meeting to address the family's concerns: An ethics committee helps resolve conflicts between families and healthcare teams while respecting patient autonomy and legal directives. This step promotes ethical decision-making and interdisciplinary collaboration.

B. Support the family's decision and initiate life-sustaining measures: Providing treatments against the client’s documented wishes violates ethical and legal standards. Advance directives must be honored, even when family members disagree.

C. Complete an incident report: An incident report is used to document errors or adverse events, not ethical conflicts. This situation requires ethical consultation and communication, not a formal incident report.

D. Encourage the family to contact an attorney: While families may seek legal counsel, it is not the nurse’s role to suggest legal action. This may escalate the conflict unnecessarily and delay proper ethical resolution.

A. “The proxy should manage legal issues for the client." B. “The proxy can make treatment decisions if the client is under anesthesia." C. “The proxy should make health care decisions for the client regardless of the client's ability to do so.” D. “The proxy can make financial decisions if the need arises."

Correct Answer is B

Explanation

Rationale:

A. "The proxy should manage legal issues for the client." A health care proxy designated through a durable power of attorney for health care is authorized to make medical not legal decisions. Legal affairs typically require a separate legal power of attorney.

B. "The proxy can make treatment decisions if the client is under anesthesia." The health care proxy is activated when the client is unable to make decisions for themselves, including temporary incapacity such as being under general anesthesia. This ensures continuity of care and respects the client’s wishes.

C. "The proxy should make health care decisions for the client regardless of the client's ability to do so." The proxy only steps in when the client is deemed incapacitated. If the client is alert and competent, they retain the right to make all decisions about their care.

D. "The proxy can make financial decisions if the need arises." A health care proxy does not have authority over financial matters. Financial decisions are managed through a separate durable power of attorney for finances, not through a health care DPAHC.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family wants the client to have life-sustaining measures. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for health care (DPAHC). Which of the following information should the charge nurse include?

Correct Answer is B

Explanation

A nurse in a provider's office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department?

A nurse is preparing to witness a client's signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (Select all that apply.)

A nurse is monitoring a client who is 36 hr postoperative following gastric banding. Which of the following findings should the nurse expect?

A nurse in an emergency department is caring for a client who is actively bleeding from a stab wound to the thigh. Which of the following actions should the nurse take?

A nurse is assessing a client who is postoperative following a coronary artery bypass graft surgery. The nurse should identify that which of the following findings is an early indication of cardiac tamponade?

The nurse continues to care for the client who is at 30 weeks of gestation. Exhibits Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.

A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take?

A nurse is caring for a client in the emergency department. Exhibits The nurse reviews the medical record. Complete the following sentence by using the lists of options The client likely experienced dropdown as evidenced by dropdown.