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. Ensuring that the client takes care of their ADLS to prevent dependence. B. Ensuring that the client environment is safe to prevent injury. C. Ensuring that the client receives food they like to prevent anxiety. D. Ensuring that the client meets the other patients to prevent social isolation.

Correct Answer is B

Explanation

A. Ensuring that the client takes care of their ADLS to prevent dependence: While promoting independence is important, ensuring safety is a higher priority to prevent immediate harm.
B. Ensuring that the client environment is safe to prevent injury: Safety is the top priority for clients with Alzheimer's due to their increased risk of falls, wandering, and other accidents. A safe environment helps prevent injuries.
C. Ensuring that the client receives food they like to prevent anxiety: Although providing familiar and preferred foods can reduce anxiety, it is not as critical as ensuring a safe environment.
D. Ensuring that the client meets the other patients to prevent social isolation: Social interaction is beneficial, but ensuring safety takes precedence to prevent potential harm.

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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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