The nurse is assisting a pregnant patient into bed after the patient reports a gush of fluid from the vagina. Which action will the nurse take first?
Place client on her left side
Notify RN immediately
Document the time and color of fluid
Check fetal heart tones
The Correct Answer is B
A. Placing the client on her left side is important for optimizing fetal oxygenation but is not the first action when there is a report of a gush of fluid.
B. Notifying the registered nurse (RN) immediately is the first action to ensure prompt assessment and appropriate interventions for possible ruptured membranes.
C. Documenting the time and color of the fluid is important, but immediate notification of the RN takes precedence.
D. Checking fetal heart tones is important but should be done in conjunction with notifying the RN to assess the overall situation and determine the appropriate course of action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
A. Carboprost (Hemabate) is a prostaglandin used to control postpartum hemorrhage.
B. Hydralazine is an antihypertensive medication, not typically used for postpartum hemorrhage.
C. Misoprostol (Cytotec) is a prostaglandin that can be used to prevent or treat postpartum hemorrhage.
D. Methylergonovine (Methergine) is an ergot alkaloid used to manage postpartum hemorrhage.
E. Oxytocin (Pitocin) is a uterotonic medication commonly used to prevent or treat postpartum hemorrhage.
Correct Answer is A
Explanation
A. Late decelerations are associated with uteroplacental insufficiency, indicating that the baby is not getting enough oxygen during contractions.
B. Maternal hypotension can lead to decreased perfusion but is more likely associated with variable decelerations.
C. Cord compression is often associated with variable decelerations, not late decelerations.
D. Head compression typically does not cause late decelerations; it may be associated with early decelerations.
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