A nurse is triaging four clients on the labor and delivery unit.
Which of the following actions should be a priority for nursing care?

Check the blood sugar of a gestational diabetic.

Assess the vaginal blood loss of a client who is recovering from a spontaneous abortion.

Assess the patellar reflexes of a client with pre-eclampsia without severe features.

Check the fetal heart rate of a client whose membranes just ruptured.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Checking blood sugar is important in gestational diabetes but isn't immediate priority in a triage setting compared to assessing urgent conditions that could harm the fetus or mother immediately.

Choice B rationale

Assessing vaginal blood loss post-abortion is crucial, but in the presence of ruptured membranes, fetal heart rate checks take precedence to ensure the fetus's immediate well-being.

Choice C rationale

Assessing patellar reflexes in pre-eclampsia management is significant, but immediate priority in labor and delivery triage goes to ensuring fetal safety after membrane rupture.

Choice D rationale

Checking the fetal heart rate after membrane rupture is a priority because it provides immediate information about the fetus's status and any potential complications like cord prolapse or distress.

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Correct Answer is C

Explanation

Choice A rationale

Magnesium sulfate is primarily used for neuroprotection in preterm infants and to prevent seizures in severe preeclampsia, not as a first-line tocolytic for preterm labor.

Choice B rationale

Morphine sulfate is an opioid analgesic used for pain management, not for inhibiting preterm labor contractions.

Choice C rationale

Terbutaline is a beta-agonist used as a tocolytic to relax uterine muscles and delay preterm labor. It helps decrease the intensity and frequency of contractions, making it suitable for managing preterm labor.

Choice D rationale

Betamethasone is a corticosteroid used to accelerate fetal lung maturity in preterm labor, not for direct contraction inhibition.

A. At what time would you like to begin the induction? B. What is the client's Bishop score? C. I am sorry but the client will not be able to be induced tomorrow. D. I will have the prostaglandin induction medication prepared.

Correct Answer is B

Explanation

Choice A rationale

Induction timing is secondary to assessing readiness. The Bishop score determines cervical favorability for induction success.

Choice B rationale

The Bishop score assesses cervical readiness for labor induction, which is vital in planning an effective induction.

Choice C rationale

Refusal to induce without considering clinical data is inappropriate. The Bishop score evaluation determines readiness.

Choice D rationale

Prostaglandin preparation follows Bishop score assessment to ensure induction safety and efficacy.

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A nurse is triaging four clients on the labor and delivery unit.Which of the following actions should be a priority for nursing care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client at 28 weeks' gestation with intact membranes is admitted with the following findings: contractions every 5 minutes lasting 60 seconds, 3 cm dilated, 80% effaced.Which of the following medications will the obstetrician likely order?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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A nurse is triaging four clients on the labor and delivery unit.
Which of the following actions should be a priority for nursing care?