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 ["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.

A. Point of maximum impulse is shifted to the right B. Weak or absent lower extremity pulses C. Apical pulse is greater than radial pulse D. Systolic murmur at the left sternal border

Correct Answer is B

Explanation

A. Point of maximum impulse is shifted to the right. This is not typically associated with coarctation of the aorta, but with other cardiac abnormalities.
B. Weak or absent lower extremity pulses. Coarctation of the aorta causes narrowing of the aorta, which restricts blood flow to the lower body, leading to diminished pulses in the lower extremities.
C. Apical pulse is greater than radial pulse. This finding is not specifically related to coarctation of the aorta.
D. Systolic murmur at the left sternal border. While murmurs may be present, coarctation typically causes a murmur best heard in the back or left infraclavicular area.

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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?

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Naxlex Comprehensive Predictor Exams

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

Explanation

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Correct Answer is B

Explanation

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