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. First trimester bleeding. Abruptio placentae typically occurs in the third trimester, not the first. First trimester bleeding is more commonly associated with miscarriage or ectopic pregnancy.
B. Severe abdominal pain. Abruptio placentae involves the premature separation of the placenta from the uterine wall, often leading to sudden, severe abdominal pain and possibly vaginal bleeding. It is a medical emergency requiring immediate attention.
C. Nausea. While nausea can occur during pregnancy, it is not a hallmark symptom of abruptio placentae and does not assist in differentiating it from other complications.
D. Delayed menses. Delayed menses may indicate early pregnancy, but it is not related to abruptio placentae, which occurs later in pregnancy.
Correct Answer is A
Explanation
A. Occupational therapist. An occupational therapist is the appropriate specialist to assess and assist with fine motor skills and daily living activities, such as eating. They can provide adaptive equipment and training to help the client maintain independence and improve quality of life.
B. Physical therapist. A physical therapist focuses primarily on gross motor skills, mobility, and physical strength, not fine motor control necessary for holding utensils. They are more involved in rehabilitation related to ambulation and transfers.
C. Dietitian. A dietitian helps develop nutritionally appropriate meal plans based on medical conditions and dietary needs. However, they do not address the client’s ability to physically manage eating tools or self-feed.
D. Social worker. A social worker provides support with emotional, financial, and community resources, but does not assist with the physical or mechanical aspects of daily tasks like feeding. They may coordinate care but not deliver direct therapy for motor challenges.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
