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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is choice A. Single palmar creases.

Choice A rationale: Single palmar creases (also known as simian creases) can be associated with certain genetic conditions, such as Down syndrome. The presence of this finding in a newborn should prompt further investigation and reporting to the healthcare provider for additional assessment and possible genetic testing.

Choice B rationale: Rust-stained urine in a newborn is typically caused by uric acid crystals, which are common and not considered abnormal during the first few days of life. This condition usually resolves without intervention, and it does not require reporting to the provider unless it persists or is accompanied by other symptoms.

Choice C rationale: Transient circumoral cyanosis is a common finding in newborns, especially when crying or feeding. It usually resolves on its own and is not considered an alarming sign unless it persists or is associated with central cyanosis or other signs of respiratory distress.

Choice D rationale: Subconjunctival hemorrhage is a common finding in newborns, usually resulting from the pressure changes during delivery. It typically resolves on its own within a few weeks and does not require reporting to the provider unless there are signs of other underlying conditions.

A. Abdominal distention. B. Jitteriness. C. Acrocyanosis. D. Hypotonia. E. Temperature instability.

Correct Answer is ["B","D","E"]

Explanation

Choice A rationale:
Abdominal distention is not typically a sign of hypoglycemia in a newborn. It could be related to other factors such as feeding issues or gastrointestinal problems.
Choice B rationale:
Jitteriness can be a sign of hypoglycemia in a newborn as low blood sugar can cause nervous system hyperactivity.
Choice C rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a sign of hypoglycemia.
Choice D rationale:
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in a newborn as low blood sugar can affect muscle function.
Choice E rationale:
Temperature instability can be a sign of hypoglycemia in a newborn as low blood sugar can affect the body’s ability to regulate temperature.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

Correct Answer is A

Explanation

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Correct Answer is ["B","D","E"]

Explanation

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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?