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A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?
- A. Administer oxytocin to the client via intravenous infusion.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Prepare for insertion of an intrauterine pressure catheter.
- D. Assist the client into the knee-chest position.
Correct Answer: D
Rationale: The correct answer is D: Assist the client into the knee-chest position. This position helps relieve pressure on the umbilical cord, preventing compression and potential harm to the fetus. By positioning the client in knee-chest, gravity can aid in moving the fetus off the cord. Administering oxytocin (choice A) is not appropriate as the priority is to relieve pressure on the cord. Applying oxygen (choice B) does not address the immediate risk posed by the cord prolapse. Insertion of an intrauterine pressure catheter (choice C) is not indicated when the priority is to alleviate cord compression.
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A client in labor with ruptured membranes is diagnosed with chorioamnionitis. What is the priority nursing action?
- A. Administer prescribed antibiotics.
- B. Encourage the client to ambulate.
- C. Increase the oxytocin infusion rate.
- D. Perform a sterile vaginal examination.
Correct Answer: A
Rationale: The correct answer is A: Administer prescribed antibiotics. The priority nursing action in a client with chorioamnionitis is to administer antibiotics promptly to prevent infection spread to the fetus and mother. Antibiotics help treat the infection and reduce complications. Encouraging ambulation (B) may not be safe due to the risk of infection. Increasing oxytocin infusion rate (C) could worsen the infection. Performing a sterile vaginal examination (D) is contraindicated as it can introduce more bacteria. Administering antibiotics is the most urgent and effective intervention in this situation.
A client at 37 weeks' gestation reports sudden gush of clear fluid. What is the nurse's priority action?
- A. Assess for fetal heart rate changes.
- B. Check maternal vital signs.
- C. Perform a sterile vaginal examination.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: The correct answer is A: Assess for fetal heart rate changes. This is the priority action because the sudden gush of clear fluid may indicate rupture of membranes, potentially leading to fetal distress. Assessing fetal heart rate changes helps determine the urgency of the situation and guides further interventions. Checking maternal vital signs (B) is important but not the priority in this scenario. Performing a sterile vaginal examination (C) should only be done after confirming rupture of membranes to prevent infection. Notifying the healthcare provider (D) can be done after assessing fetal well-being.
A nurse is monitoring a client who has preeclampsia and is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse reports to the provider?
- A. Blood pressure 148/94mm Hg
- B. Respiratory rate 14mm
- C. Urinary output 20 mL/hr
- D. 2+deep tendon reflexes
Correct Answer: A
Rationale: The correct answer is A: Blood pressure 148/94mm Hg. High blood pressure in a client with preeclampsia indicates worsening condition and potential for eclampsia. Magnesium sulfate is given to prevent seizures, so high blood pressure needs immediate provider attention.
Incorrect Choices:
B: Respiratory rate 14mm - This respiratory rate is within normal range.
C: Urinary output 20 mL/hr - Low urinary output should be monitored but is not the priority in this situation.
D: 2+deep tendon reflexes - Normal deep tendon reflexes are expected with magnesium sulfate therapy.
A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make? to
- A. "You should go ahead and push to assist the delivery."
- B. "You should try to pant as the delivery proceeds."
- C. "You should try to perform slow-paced breathing."
- D. "You should take a deep, cleansing breath and breathe naturally."
Correct Answer: A
Rationale: The correct answer is A because the newborn's head crowning indicates imminent delivery, and the client's urge to push aligns with the natural progression of labor. By encouraging the client to push, the nurse facilitates the safe and timely delivery of the baby. Panting (choice B) or slow-paced breathing (choice C) may not be effective in this advanced stage of labor. Taking a deep cleansing breath (choice D) can delay the delivery and is not recommended when the baby is crowning.
A 23-year-old female patient is considering intrauterine device (IUD) contraception. What is the most important information to assess before placement?
- A. Is there any family history of heart disease?
- B. Are you allergic to any metals?
- C. Have you had any previous IUDs inserted?
- D. Do you have a history of hypertension?
Correct Answer: B
Rationale: The correct answer is B: Are you allergic to any metals? This is crucial because some IUDs contain metals like copper, which can trigger allergic reactions in individuals with metal allergies. It is important to assess for metal allergies to prevent potential adverse reactions.
Incorrect Choices:
A: Family history of heart disease is not directly relevant to IUD placement.
C: Previous IUD insertions are important for clinical history but do not impact the initial assessment for a new insertion.
D: History of hypertension is important for overall health assessment but does not directly affect IUD placement.