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 an oxytocin IV infusion
Apply a fetal heart rate monitor.
Initiate fundal massage.
Insert an indwelling urinary catheter
The Correct Answer is B
A. Initiate an oxytocin IV infusion. Oxytocin may be used to augment labor, but it should not be started immediately without first assessing maternal and fetal well-being. Continuous monitoring is necessary before initiating any uterotonic agent.
B. Apply a fetal heart rate monitor. After rupture of membranes, assessing the fetal heart rate is critical to detect signs of umbilical cord prolapse or fetal distress. Continuous electronic fetal monitoring helps evaluate the baby's response to labor.
C. Initiate fundal massage. Fundal massage is performed after delivery of the placenta to help contract the uterus and reduce postpartum bleeding. It is not appropriate during active labor.
D. Insert an indwelling urinary catheter. A catheter may be placed if necessary during labor, especially before epidural anesthesia, but it is not the immediate priority following membrane rupture. Fetal monitoring takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Silence the bed alarm when visitors are at the client's bedside. Bed alarms are a critical safety device for clients on fall precautions and should never be silenced when the client is in bed, regardless of visitors. Alarms alert staff if the client attempts to get up unsafely.
B. Establish an elimination schedule for the client. A regular toileting schedule helps reduce the risk of falls by preventing unassisted attempts to get out of bed to use the bathroom. This proactive approach supports both safety and comfort.
C. Raise all four bed rails on the client's bed. Raising all four rails is considered a form of restraint and can actually increase the risk of injury if the client attempts to climb over them. Two rails up is generally acceptable for support and safety.
D. Allow the client to walk unassisted near the nursing station. Clients on fall precautions should always be supervised or assisted during ambulation to prevent accidents, even when close to staff. Being near the nursing station does not eliminate the risk.
Correct Answer is ["A","D"]
Explanation
A. Medicaid. Medicaid provides health coverage for low-income individuals, including young adults who meet poverty guidelines. It can cover home health services and IV therapy, making it an appropriate resource for this client.
B. Medicare Part A. Medicare Part A generally covers hospital care and limited home health services, but it is primarily for individuals aged 65 and older or those with certain disabilities. It is not typically available to young adults without qualifying conditions.
C. Respite care. Respite care provides temporary relief to caregivers, not direct services for clients requiring IV therapy. It is more relevant for individuals with long-term caregiving needs, not this scenario.
D. Food stamps. Also known as the Supplemental Nutrition Assistance Program (SNAP), food stamps assist low-income individuals in accessing food. It’s a valuable support service for someone living below the poverty line.
E. Adult day care. This is intended for older adults or individuals with disabilities who need supervision during the day. It is not applicable for a young adult requiring home IV therapy.
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