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
The practical nurse (PN) should obtain information about the client's current medications, including any analgesics or antianxiety medications that may be contributing to the confusion. These medications can cause cognitive impairment and confusion, especially in older adults. It is important to assess the client's mental status and identify any potential causes of confusion, as this can indicate a change in the client's condition that requires further evaluation and intervention.
Option B is incorrect as it refers to a history of situational depression, which may not be relevant to the current situation.
Option C is also incorrect as it refers to previous falls, which may not be related to the current confusion.
Option D is incorrect as it refers to the client's history of alcohol abuse, which may be important to know but is not the most relevant information to obtain in this situation.
Correct Answer is D
Explanation
Feeling sad or having a depressed mood is a common symptom of depression. Asking the client if they often feel sad can help the practical nurse (PN) assess for depression.
While recent stresses (A), sleep changes (B), and dietary habits (C) may also be relevant to the client's situation, asking if the client often feels sad is the most important question for the PN to ask in order to further assess for depression.
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