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 C
Explanation
A. "Take your temperature every night before going to bed." Basal body temperature (BBT) must be measured after a full night’s sleep, not at bedtime, to accurately detect ovulatory shifts in temperature.
B. "Take your temperature 1 hour after getting out of bed." Delaying the measurement even by an hour can alter the results, as physical activity and environmental exposure can cause inaccurate readings.
C. "Take your temperature immediately after waking and before getting out of bed." This is the correct instruction. BBT should be taken at the same time each morning, right after waking, before any activity, to detect the slight rise in temperature (0.3–0.6°C or 0.5–1.0°F) that typically follows ovulation.
D. "Take your temperature within 30 minutes after your first morning void." Waiting until after voiding can also affect the reading. The temperature should be taken prior to any physical movement, including going to the bathroom, for best accuracy.
Correct Answer is B
Explanation
A. "Morphine 3.0 mg sub q every 4 hr PRN for pain." Including a trailing zero (3.0 mg) is considered unsafe and is discouraged in medication documentation. It increases the risk of a tenfold overdose if the decimal is missed.
B. "Morphine 3 mg subcutaneous every 4 hr PRN for pain." This entry uses the correct dosage format without a trailing zero, the full term "subcutaneous" instead of abbreviations, and proper medical terminology. It adheres to safe documentation practices as per The Joint Commission guidelines.
C. "Morphine 3 mg SC q 4 hr PRN for pain." The abbreviation “SC” is considered unsafe and prone to misinterpretation. Also, "q" for "every" is discouraged in clinical documentation due to potential misreading and error.
D. "Morphine 3 mg SQ every 4 hr PRN for pain." The abbreviation “SQ” can be misinterpreted or mistaken for “5 every” or other terms. Safe practice requires spelling out “subcutaneous” to prevent errors in medication administration.
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