A nurse is caring for a client who is experiencing an amniotic fluid embolism during labor.
Which of the following actions should the nurse take?
Plan to administer ephedrine IV.
Assist the client to empty their bladder.
Assess for the presence of clonus.
Prepare to initiate cardiopulmonary resuscitation.
The Correct Answer is D
Choice A rationale:
Administering ephedrine IV is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. Ephedrine is typically used to treat hypotension during spinal anesthesia, not amniotic fluid embolism.
Choice B rationale:
Assisting the client to empty their bladder is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. While bladder care is important, it is not the priority in this situation.
Choice C rationale:
Assessing for the presence of clonus is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. Clonus is typically assessed in clients with preeclampsia or eclampsia, not amniotic fluid embolism.
Choice D rationale:
Preparing to initiate cardiopulmonary resuscitation is the appropriate action for a client experiencing an amniotic fluid embolism during labor. Amniotic fluid embolism can lead to cardiovascular collapse, therefore, immediate resuscitation measures should be prepared15.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Evaluating urinary output is important postoperatively, but it does not address the immediate concern of vaginal bleeding.
Choice B rationale:
Replacing the surgical dressing is necessary if it’s saturated, but it does not address the immediate concern of vaginal bleeding.
Choice C rationale:
Applying an ice pack to the incision site can help reduce swelling and pain, but it does not address the immediate concern of vaginal bleeding.
Choice D rationale:
Administering a 500 mL lactated Ringer’s IV bolus can help increase uterine contractility and decrease bleeding. This is the most appropriate action for the nurse to take in this situation.
Correct Answer is D
Explanation
Choice A rationale:
Giving oxytocin 20 units IV bolus is incorrect. Oxytocin is used to stimulate uterine contractions, not to stop bleeding.
Choice B rationale:
Performing a fundal massage is incorrect. This is done to stimulate uterine contractions, not to stop bleeding.
Choice C rationale:
Assessing for abdominal tenderness is incorrect. This is not a priority action when a client is exhibiting a large amount of vaginal bleeding.
Choice D rationale:
Obtaining serial hemoglobin and hematocrit is correct. These lab tests will help determine the extent of blood loss and guide treatment.
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