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. Use physical restraints during severe outbursts to ensure safety: Restraints should only be used as a last resort and are not an effective or ethical primary strategy for managing behavior in children with ODD.
B. Assign daily chores that are challenging to encourage discipline: Assigning overly challenging chores may lead to frustration and non-compliance, exacerbating behavioral issues rather than helping.
C. Encourage solitary play to reduce social stressors: Isolating the child may worsen feelings of exclusion and does not address the need for social skills development and appropriate behavior in social contexts.
D. Put into practice consistent consequences for rule-breaking behavior: Consistency in consequences helps the child understand boundaries and the importance of following rules, which is crucial for managing behavior in ODD.
Correct Answer is D
Explanation
A. Assess motor function in lower extremities: While important for overall neurological assessment, immediate post-repair monitoring of motor function is secondary to monitoring for signs of hydrocephalus (head circumference).
B. Maintain skin integrity: Essential for preventing infection but does not address the immediate post-surgical complication of hydrocephalus.
C. Monitor intake and output: Important for general post-operative care but does not address the immediate concern of monitoring for hydrocephalus.
D. Monitor head circumference: Following repair of a myelomeningocele, infants are at risk for developing hydrocephalus due to abnormal cerebrospinal fluid dynamics. Monitoring head circumference helps detect early signs of increased intracranial pressure, a common complication post-surgery.
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