The nurse is caring for a laboring client who presents with ruptured membranes, frequent contractions, and bloody show. Which intervention should be performed first?
Establish IV access
Assess the client's vital signs
Obtain fetal heart rate
Perform a sterile vaginal exam
The Correct Answer is C
A. Establish IV access: Although important for hydration and medication administration, it is not the immediate priority when assessing the fetal condition.
B. Assess the client's vital signs: While important, the immediate assessment of fetal well-being takes precedence to ensure there is no fetal distress.
C. Obtain fetal heart rate: This is crucial to assess the fetus’s condition immediately. Monitoring the fetal heart rate can identify any signs of distress and determine if urgent interventions are necessary.
D. Perform a sterile vaginal exam: This should follow the fetal heart rate assessment to check for labor progress and any complications, but it is not the first priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "The most common manifestation of postpartum depression is harming the infant." This is incorrect; harming the infant is a severe complication but not the most common manifestation.
B. "It's common for clients who have postpartum depression to exhibit psychotic behavior." Psychotic behavior is a rare but serious complication of postpartum depression.
C. "Postpartum depression usually begins 48 hours after childbirth." Postpartum blues may start within this timeframe, but postpartum depression typically manifests later.
D. "Postpartum depression is more likely to occur in women who have a history of depression." This statement correctly identifies a significant risk factor for postpartum depression.
Correct Answer is B
Explanation
A. The elevated AFP means my baby may have Down Syndrome. AFP is not typically elevated in Down Syndrome; other tests like nuchal translucency or cell-free DNA are used for that.
B. The elevated AFP means my baby may have spina bifida. AFP screening is used to detect neural tube defects like spina bifida. An elevated AFP level suggests a higher risk for such conditions.
C. The elevated AFP means my baby has Down syndrome. This is incorrect; AFP is not a marker for Down Syndrome.
D. The elevated AFP means my baby has spina bifida. This is correct, but option B is a more precise statement of understanding.
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