The practical nurse (PN) is assigned to assist in the care of a client at 34-weeks gestation with premature rupture of membranes (PROM). Four hours after admission, the PN recognizes an increasing trend in the maternal heart rate. Which action should the PN take?
Follow contact precautions when providing care.
Insert a urinary catheter to monitor hourly output.
Encourage the client to push with the next contraction.
Initiate oxygen via face mask at 8 to 10 L/min.
The Correct Answer is D
An increasing trend in maternal heart rate is a sign of fetal distress, which can be a serious complication of PROM. One of the primary interventions for fetal distress is to increase oxygen delivery to the fetus. The practical nurse should initiate oxygen via face mask at 8 to 10 L/min to improve fetal oxygenation.
Contact precautions may be necessary for certain conditions, but they are not indicated for an increasing maternal heart rate.
Inserting a urinary catheter may be appropriate for monitoring output, but it is not the first priority in this situation.
Encouraging the client to push is not appropriate because the client is not in active labor and pushing can cause further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Vitamin tablets are unlikely to cause significant harm to the esophagus if the child vomits after ingesting them. However, toilet bowl cleaner and kerosene are corrosive substances that can cause serious damage to the esophagus and other tissues if ingested.
An unknown substance cannot be evaluated for potential harm to the esophagus.
In any case, the mother should be advised to seek immediate medical attention for her child if they have ingested any potentially harmful substance.
The PN should also follow their facility's policies and procedures for managing cases of poisoning or suspected poisoning.
Correct Answer is A
Explanation
In this situation, the practical nurse (PN) should coach the client to take slow, deep breaths during each contraction. The client has already been medicated with butorphanol and promethazine for pain relief and it may not be appropriate to administer another dose at this time. Instead, the PN can provide non- pharmacological pain relief measures such as coaching the client to use breathing techniques to help manage the pain during contractions. The other actions listed may also be appropriate in some situations, but coaching the client to use breathing techniques is the most appropriate action in this situation.
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