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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Boil bottle rings and nipples for 10 min to ensure sanitization. Boiling for 10 minutes is excessive and can damage bottle parts. A boil time of 5 minutes is typically sufficient for sanitizing feeding equipment before first use.
B. Keep the newborn on a strict 3 hr feeding schedule. Newborns should be fed on demand, which may be more or less frequently than every 3 hours. Hunger cues should guide feeding to promote healthy growth and bonding.
C. Use bottles of refrigerated formula within 48 hr. Prepared formula should be refrigerated and used within 48 hours to ensure safety and prevent bacterial growth. This is a safe practice when storing formula that has not been fed to the infant.
D. Place the newborn on their abdomen for 30 min following each feeding. Placing a newborn on the abdomen increases the risk of sudden infant death syndrome (SIDS). Infants should always be placed on their backs to sleep.
Correct Answer is C
Explanation
A. Hyperthyroidism. This condition is not a contraindication to the use of combination oral contraceptives. Women with hyperthyroidism can generally use hormonal contraceptives safely under medical supervision.
B. Hypocalcemia. Low calcium levels are not linked to increased risk with combination oral contraceptives and do not contraindicate their use.
C. Thrombophlebitis. This condition involves inflammation and clot formation in the veins, and is a major contraindication to combination oral contraceptives. These medications increase the risk of blood clots, making them unsafe for clients with current or prior thromboembolic disorders.
D. Diverticulosis. This gastrointestinal condition is not affected by hormone levels and is not a contraindication to combination oral contraceptive use.
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