A client who is in active labor is admitted to a labor and delivery unit reporting "My water just broke and my baby is breech.”. Which of the following actions should the nurse take first?

Check fetal heart tones.

Prepare for a cesarean birth.

Check the color, amount, and odor of the fluid.

Perform Nitrazine test to assess for rupture of membranes.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Checking fetal heart tones is the priority to assess the well-being of the fetus, especially in breech presentation and after the membranes have ruptured.

Choice B rationale

Preparing for a cesarean birth is important but follows the assessment of fetal heart tones and other immediate measures.

Choice C rationale

Checking the color, amount, and odor of the fluid is important, but ensuring fetal heart tones comes first to monitor any distress.

Choice D rationale

Performing a Nitrazine test to assess for rupture of membranes is redundant once the client reports her water has broken.

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Correct Answer is C

Explanation

Choice A rationale

Cooling the newborn’s heel would constrict blood vessels and make it more difficult to obtain a blood sample. Warming the heel is the preferred method to increase blood flow.

Choice B rationale

Puncturing the center of the newborn’s heel is not recommended as it could cause more pain and potential injury to the bone. The puncture should be done on the outer edges of the heel.

Choice C rationale

Cleansing the puncture site with alcohol gauze is essential to reduce the risk of infection and ensure that the sample is not contaminated.

Choice D rationale

Administering vitamin K before each blood draw is unnecessary. Vitamin K is typically given as a one-time dose to prevent bleeding issues, not related to blood draw procedures.

A. Manifestations of shock might not appear until a client loses 20% of their blood volume. B. Hemorrhagic shock will cause an increase in a client's serum pH. C. The most accurate indication of organ perfusion is a client's urine output. D. An infusion of 1 mL of lactated Ringers is given for each 1 mL of blood loss.

Correct Answer is A

Explanation

Choice A rationale

Manifestations of shock might not appear until a client loses 20% of their blood volume. This is because the body compensates for blood loss by increasing heart rate and vasoconstriction, maintaining blood pressure until a significant amount of blood is lost.

Choice B rationale

Hemorrhagic shock will cause a decrease, not an increase, in a client's serum pH due to the accumulation of lactic acid from anaerobic metabolism, leading to metabolic acidosis.

Choice C rationale

The most accurate indication of organ perfusion is a client's urine output. Adequate urine output reflects sufficient renal blood flow and overall perfusion, making it a reliable indicator of organ perfusion.

Choice D rationale

An infusion of 1 mL of lactated Ringers for each 1 mL of blood loss is not accurate. The typical fluid replacement ratio is 3:, meaning 3 mL of crystalloid solution (like lactated Ringers) is given for each 1 mL of blood loss to account for fluid distribution in the body.

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A client who is in active labor is admitted to a labor and delivery unit reporting "My water just broke and my baby is breech.”. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to obtain a blood specimen from a newborn via a heel stick.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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