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In preparing a gravid client for a triple screen analysis, which action should the nurse take?

Encourage the client to drink 8 oz of water.

Assist the client to left lateral tilt position.

Prepare to draw blood for analysis.

Apply an external fetal monitor to the abdomen.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Drinking water is not necessary before a triple screen analysis. This test does not require a full bladder.

Choice B rationale

The left lateral tilt position is typically used to prevent supine hypotensive syndrome in pregnant women during ultrasounds, not for a blood draw.

Choice C rationale

A triple screen analysis involves drawing blood from the mother to test for specific markers that indicate the risk of certain fetal abnormalities. Blood sampling is necessary for the analysis.

Choice D rationale

Applying an external fetal monitor is unrelated to a triple screen analysis, which focuses on maternal blood markers rather than fetal heart rate monitoring.

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Correct Answer is D

Explanation

Assessing vital signs is important but not the most immediate action for heavy postpartum bleeding. It provides information about the client's current status but does not address the bleeding directly.

Choice B rationale

Increasing the IV infusion rate can help manage blood loss by maintaining blood volume, but it is not the first action to take when managing postpartum hemorrhage.

Choice C rationale

Notifying the healthcare provider is important but secondary to addressing the immediate cause of the bleeding. The provider will need information about the client's status and the actions taken to manage the situation.

Choice D rationale

Massaging the fundus is the most immediate and effective action to reduce postpartum hemorrhage. It stimulates uterine contractions, which helps to clamp down on the blood vessels and stop the bleeding.

A. Perform a vaginal exam. B. Take vital signs. C. Palpate the bladder. D. Examine the amniotic fluid. E. Dipstick urine for protein and ketones.

Correct Answer is ["A","B"]

Explanation

Choice A rationale

Performing a vaginal exam is crucial in assessing the progress of labor and the condition of the cervix, particularly if the client has reported symptoms such as contractions, bleeding, or fluid leakage. It helps determine if the client is in active labor or if there are any complications requiring immediate intervention.

Choice B rationale

Taking vital signs is essential to assess the client's overall health and identify any signs of distress or complications. Vital signs provide critical information about the client's cardiovascular and respiratory status, which is important for immediate clinical decision-making.

Choice C rationale

Palpating the bladder is important in assessing for bladder distention, which can impede labor progress or cause discomfort. However, it is not the immediate priority compared to assessing labor progress and overall health status.

Choice D rationale

Examining the amniotic fluid is important for determining its characteristics, which can provide information about the fetal well-being. However, this action is secondary to performing a vaginal exam and taking vital signs in the immediate assessment.

Choice E rationale

Dipstick urine for protein and ketones helps in assessing for preeclampsia or gestational diabetes, but it does not address the immediate need to assess labor progress and the client's overall health status.

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In preparing a gravid client for a triple screen analysis, which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a postpartum client who delivered 5 hours ago, and has saturated a perineal pad with clots within the last 15 minutes.Which action is most important for the nurse to implement?

Correct Answer is D

Explanation

The nurse determines the need to perform further assessment based on the client's situation.Select the 2 actions that the nurse should perform immediately.

Correct Answer is ["A","B"]

Explanation

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At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache.Which action should the nurse take first?

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