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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. "Apply cold compresses when your child expresses pain." Cold can cause vasoconstriction, which may precipitate a sickle cell crisis by reducing blood flow to the extremities, thus increasing the risk of sickling of red blood cells. Warm compresses are recommended to help alleviate pain by promoting blood flow.
B. "Restrict outdoor play activity to 1 hour per day." While it's important to monitor physical activity to avoid overexertion, restricting outdoor play to a specific time frame without considering other factors like hydration and rest isn't the right approach. Physical activity is important but should be balanced with adequate hydration and rest.
C. "Monitor your child's temperature daily." While monitoring temperature is important, it isn't specifically critical on a daily basis unless there is a suspicion of infection. The primary focus should be on hydration and recognizing signs of infection.
D. "Offer fluids to your child multiple times every day." Hydration is crucial for children with sickle cell anemia as it helps to prevent sickling of cells by maintaining good blood flow and preventing dehydration, which can trigger a crisis.

A. Offer the newborn a pacifier B. Observe the newborn in a well-lit nursery C. Maintain low stimulation environment D. Administer oral glucose for comfort E. Swaddle newborn tightly F. Feed the infant half strength formula

Correct Answer is ["A","C","E"]

Explanation

A. Offer the newborn a pacifier. This can help soothe the newborn and provide comfort, as infants exposed to opioids in utero often exhibit increased need for sucking.
B. Observe the newborn in a well-lit nursery. This is not appropriate as bright lights can overstimulate and distress the newborn.
C. Maintain a low stimulation environment. This helps reduce stress and irritability in newborns undergoing withdrawal, who can be hypersensitive to stimuli.
D. Administer oral glucose for comfort. Glucose is not typically used for comfort in NAS management; comforting measures like swaddling and pacifiers are preferred.
E. Swaddle the newborn tightly. Tight swaddling can provide a sense of security and help manage symptoms of neonatal abstinence syndrome (NAS) by reducing irritability and promoting sleep.
F. Feed the infant half-strength formula. Infants with NAS usually require regular, full-strength formula to meet nutritional needs unless otherwise indicated by specific feeding issues.

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The nurse is caring for a laboring client who presents with ruptured membranes, frequent contractions, and bloody show. Which intervention should be performed first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is ["A","C","E"]

Explanation

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