The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 station. An hour later. she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

Review the fetal heart rate pattern

Check the pH of the vaginal fluid

Determine cervical dilation.

Palpate the client's bladder

Answer and Explanation

The Correct Answer is D

A. Review the fetal heart rate pattern: Checking the fetal heart rate (FHR) pattern is crucial during labor to ensure the baby is tolerating labor well and there are no signs of fetal distress. However, when the client expresses a need to use the bathroom, this may not be the immediate action required.

B. Check the pH of the vaginal fluid: Checking the pH of the vaginal fluid is not typically an initial action when a laboring client expresses a need to go to the bathroom. Monitoring the pH may be relevant for various reasons, but it's not a primary consideration in this context.

C. Determine cervical dilation: The initial examination revealed the cervix was 3 cm dilated. While reassessing the cervical dilation could provide information about the progress of labor, it may not be the most immediate action needed when the client wants to use the bathroom.

D. Palpate the client's bladder: This is the most relevant action when a laboring client expresses a desire to go to the bathroom. Palpating the bladder can help determine if it's full, which is important because a full bladder might impede labor progress or cause discomfort during contractions.

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Correct Answer is C

Explanation

A. Assign a practical nurse (PN) to reassess the client's vital signs:
While reassessing vital signs is important, the reported severe headache after delivery is a symptom that requires immediate attention. It's more appropriate for a licensed professional, such as the nurse or healthcare provider, to assess and decide the course of action.

B. Obtain a STAT hemoglobin and hematocrit:
While assessing hemoglobin and hematocrit can provide information about potential postpartum hemorrhage, it may not be the first action needed in this context. The severe headache suggests a possible neurological concern that should be addressed promptly.

C. Notify the healthcare provider of the assessment findings:
This is the most appropriate initial action. Severe headache after delivery, especially if the client had received anesthesia, could be indicative of post-dural puncture headache (PDPH). Prompt notification allows the healthcare provider to assess and decide on the necessary interventions.

D. Determine if the client received anesthesia during delivery:
Knowing the type of anesthesia is important for understanding potential complications. However, this information alone might not guide immediate actions. The focus should be on addressing the reported severe headache promptly.

A. Sleep deprivation. B. Fluid volume excess C. Nausea and vomiting D. Risk for infection.

Correct Answer is B

Explanation

A. Sleep deprivation:

While sleep is important for overall well-being, it may not be the top priority in this case. Fluid volume excess, given the client's cardiac history, poses a more immediate threat to health.

B. Fluid volume excess:

Clients with heart damage are prone to heart failure, and managing fluid balance is crucial. Excess fluid can worsen cardiac function, making this the priority concern.

C. Nausea and vomiting:

While nausea and vomiting are significant concerns, they might not be as directly related to the client's cardiac history as fluid volume excess. However, if severe, it could contribute to fluid imbalance.

D. Risk for infection:

Infection is a concern for postpartum clients, but in this case, the client's history of rheumatic fever and heart damage takes precedence. The priority is to prevent complications related to heart failure.

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The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 station. An hour later. she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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