A nurse is caring for a client who is in labor.

Exhibits

Select the 5 actions the nurse should take.

Exert upward pressure on the presenting part.

Place the client in a Trendelenburg position.

Administer oxygen at 10 L/min via nonrebreather face mask.

Attempt to push the umbilical cord back into the cervix.

Have the charge nurse notify the provider.

Increase the flow rate of the maintenance IV fluid.

Answer and Explanation

Correct Answer : A,B,C,E,F

A. Exert upward pressure on the presenting part. If there are signs of cord prolapse or pressure on the umbilical cord, exerting upward pressure on the presenting part can relieve compression. This action helps maintain blood flow and oxygen supply to the fetus.

B. Place the client in a Trendelenburg position. Positioning the client with the pelvis elevated higher than the head can reduce pressure on the umbilical cord if prolapse is suspected or confirmed. This promotes fetal circulation and decreases the risk of hypoxia.

C. Administer oxygen at 10 L/min via nonrebreather face mask. Administering high-flow oxygen increases maternal oxygenation, which in turn improves oxygen delivery to the fetus. This is a priority intervention to ensure fetal well-being during labor.

D. Attempt to push the umbilical cord back into the cervix. This is incorrect because pushing the cord back into the cervix is contraindicated due to the risk of damaging the cord or introducing infection. Other measures, such as repositioning and elevating the presenting part, should be prioritized instead.

E. Have the charge nurse notify the provider. Timely communication with the provider is critical when complications arise during labor, such as suspected umbilical cord prolapse. The provider may need to intervene urgently, possibly requiring an emergency cesarean section.

F. Increase the flow rate of the maintenance IV fluid. Increasing the IV fluid rate helps improve maternal circulation and blood flow to the uterus and placenta, ensuring the fetus receives adequate oxygen and nutrients. This is a supportive measure during labor when complications arise.

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Correct Answer is B

Explanation

A. Clean gloves (not sterile) are sufficient for collecting a sputum sample.

B. The best time to collect a sputum specimen is immediately upon waking because secretions accumulate overnight, making it easier to obtain a sample.

C. Waiting a day delays diagnosis and treatment; other techniques can help induce sputum production.

D. Typically, 5 to 10 mL of sputum is sufficient for diagnostic testing.

A. Blood pressure B. Urine ketones C. Urine protein Gravida/parity D. Report of headache E. Respiratory rate F. Fetal activity

Correct Answer is ["A","C","D","F"]

Explanation

A. Blood pressure. A blood pressure of 162/112 mm Hg is severely elevated and indicative of preeclampsia, a serious complication during pregnancy. Uncontrolled hypertension can lead to maternal and fetal complications, such as eclampsia, placental abruption, or fetal growth restriction.

B. Urine ketones. The absence of ketones in the urine is normal and does not indicate any prenatal complication. Ketones would typically be seen in cases of starvation, dehydration, or poorly controlled diabetes, which are not evident here.

C. Urine protein. The presence of 3+ protein in the urine is a key diagnostic marker for preeclampsia. This finding, combined with elevated blood pressure, signals potential damage to the kidneys, which is a hallmark of severe preeclampsia.

D. Report of headache. A severe headache unrelieved by acetaminophen is a concerning symptom of preeclampsia. It suggests potential central nervous system involvement, which could lead to complications like seizures if left untreated.

E. Respiratory rate. The client’s respiratory rate of 16/min is within the normal range and does not indicate any immediate concern related to her pregnancy or current condition.

F. Fetal activity. The client’s report of decreased fetal movement is concerning and may indicate fetal distress or compromised placental function. This finding requires prompt evaluation to ensure fetal well-being.

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Body Systems	Findings
Respiratory	Respiratory rate 26/min
Cardiovascular	Heart rate 112/min Capillary refill 4 seconds
Gastrointestinal	Hyperactive bowel sounds
Integumentary	Diaper area reddened with erythema noted Extremities cool Reports no tears
Neurologic	Lethargic

A nurse is caring for a client who is in labor. Exhibits Select the 5 actions the nurse should take.

Nursing Test Bank

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A nurse is caring for a client who is in labor. Exhibits Select the 5 actions the nurse should take.

A nurse is caring for a client who is in labor.

Exhibits

Select the 5 actions the nurse should take.