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.
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Related Questions
Correct Answer is D
Explanation
A. Playing on the backyard swings and running around outside are exercises our child will really enjoy. Encouraging physical activity is beneficial as it helps with lung function and overall health.
B. Three to four times a day we will perform chest therapy and postural drainage on our child. This is correct and necessary to help clear mucus from the lungs.
C. A high protein, high-calorie diet may need to be supplemented with a high-calorie formula. This is important for meeting the nutritional needs of children with cystic fibrosis due to their higher caloric requirements.
D. Pancreatic enzymes will not be necessary if our child has a good appetite and regular bowel movements. This is incorrect; children with cystic fibrosis typically need pancreatic enzyme supplements with every meal and snack to aid digestion, regardless of appetite or bowel regularity.
Correct Answer is B
Explanation
A. Hypoplastic heart syndrome: Characterized by underdevelopment of the left side of the heart, not mixing of blood.
B. Atrioventricular canal defect: An atrioventricular canal defect allows oxygenated and deoxygenated blood to mix due to the presence of a common atrioventricular valve and defects in the atrial and ventricular septa. This defect results in a mixture of oxygenated and deoxygenated blood, which can cause varying levels of oxygenation in the blood delivered to the body.
C. Tetralogy of Fallot: Involves a ventricular septal defect leading to right-to-left shunting, but not a direct mixing of oxygenated and deoxygenated blood.
D. Coarctation of the aorta: Involves narrowing of the aorta, not mixing of oxygenated and deoxygenated blood.
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