A primigravida client at 36-weeks gestation is admitted to the labor and delivery unit because her membranes ruptured 30 minutes ago. Initial assessment indicates a 2 cm cervical dilatation, 50% effaced, -2 station, vertex presentation, greenish-colored amniotic fluid, and contractions occurring every 3 to 5 minutes, with a decrease in fetal heart rate after the last four contraction peaks. Which action should the nurse implement first?
Administer oxygen via face mask.
Apply an Internal fetal heart monitor.
Notify the healthcare provider.
Use a vibroacoustic stimulator.
The Correct Answer is A
A. Administer oxygen via face mask. The decrease in fetal heart rate after contractions indicates possible fetal distress. Administering oxygen to the mother can increase oxygen delivery to the fetus, potentially improving fetal oxygenation and alleviating distress.
B. Apply an Internal fetal heart monitor. While continuous monitoring is important, the first priority is to address the immediate fetal distress. Monitoring alone will not address the issue.
C. Notify the healthcare provider. Notifying the provider is important, but addressing the immediate fetal distress takes priority.
D. Use a vibroacoustic stimulator. Vibroacoustic stimulation can be used to assess fetal well- being, but it does not address the underlying fetal distress, which is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Measure and record the client's urinary output every day.
While monitoring urinary output is important, it is not as directly related to the safety concerns associated with the new medications and the client's current state.
B. Obtain a blood pressure reading before the client gets out of bed.
This is the correct answer because both antidepressants and sedatives can cause orthostatic hypotension, which could lead to falls or other complications. Monitoring blood pressure before the client gets up helps to prevent these issues.
C. Obtain the client's vital signs every 4 hours when awake.
Regular vital sign monitoring is important, but specific attention to orthostatic changes is more critical in this scenario.
D. Provide the client with teaching regarding a cardiac diet.
While dietary education is important for long-term health management, it does not address the immediate risk associated with the prescribed medications and potential orthostatic hypotension.
Correct Answer is C
Explanation
A. Cover client with cooling blanket.
This could help manage the fever but is not the highest priority in the context of acute adrenal crisis.
B. Obtain an analgesic prescription.
Pain management is important, but it is not the immediate priority in a life-threatening adrenal crisis.
C. Infuse an intravenous fluid bolus.
This is the correct answer because the client is experiencing hypotension (low blood pressure), which is critical in an acute adrenal crisis. IV fluids are essential to restore blood pressure and perfusion.
D. Administer PRN oral antipyretic.
Managing the fever is important, but not the first priority. The client’s hemodynamic instability needs to be addressed immediately.
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