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 C
Explanation
For a child with heart failure, the greatest priority for the practical nurse (PN) is to conserve the child's energy. Clustered care activities and rest periods will help to conserve the child's energy and minimize the workload on the heart.
Monitoring therapeutic levels of phenytoin (A) is not relevant to the care of a child with heart failure. Increasing fluid intake (B) is not a priority intervention for a child with heart failure, as excessive fluid intake can worsen heart failure. Restricting intake of foods high in sugar (D) may be necessary for a child with heart failure, but it is not the greatest priority for the PN to address.
Correct Answer is A
Explanation
A male client with paranoia can be expected to exhibit behavior such as being **openly hostile to others for no apparent reason**. Paranoia is a mental health condition characterized by intense and irrational mistrust or suspicion of others. This can lead to hostility and aggression towards others, even when there is no apparent reason for it.
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