A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum.
Which action should the nurse perform first?

Place the client in Trendelenburg.

Notify the operating room team.

Administer oxygen via face mask.

Administer a fluid bolus of 500 mL.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Placing the client in Trendelenburg position is the first action as it helps to relieve pressure off the umbilical cord by using gravity to shift the fetus away from the pelvis. This position helps to prevent cord compression and maintain blood flow to the fetus.

Choice B rationale

Notifying the operating room team is important but should be done after immediately addressing the umbilical cord prolapse to prevent fetal hypoxia. Initial physical intervention takes priority.

Choice C rationale

Administering oxygen via face mask is beneficial for the mother and fetus but is not the immediate first action. Positioning the client to relieve pressure off the umbilical cord is more urgent.

Choice D rationale

Administering a fluid bolus of 500 mL can help maintain maternal blood pressure, but it is not the first action. The priority is to reposition the client to prevent cord compression.

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Correct Answer is C

Explanation

Choice A rationale

Jarisch-Herxheimer reaction is seen in spirochete infections like syphilis or Lyme disease, not typically in pelvic inflammatory disease (PID) treated with antibiotics like levofloxacin and metronidazole.

Choice B rationale

Serial anaerobic cultures are not routine for PID management. Diagnosis and management focus more on clinical symptoms and empirical antibiotic therapy rather than continuous culture monitoring.

Choice C rationale

Supervised parenteral antibiotic protocols ensure proper dosage and administration, crucial for severe infections requiring hospitalization. Monitoring treatment in a controlled environment increases effectiveness and reduces complications.

Choice D rationale

While infection control is important, PID typically spreads through sexual contact, and hospital admission for infection control is not the primary reason. The focus is more on effective treatment delivery in severe cases. .

Correct Answer is ["2.3"]

Explanation

Step 1 is to convert the child's weight from pounds to kilograms. 16 pounds ÷ 2.2 = 7.3 kg.

Step 2 is to calculate the total daily dose in mg. 25 mg/kg × 7.3 kg = 182.5 mg.

Step 3 is to determine the dose per administration, divided by 2 since the dose is given every 12 hours. 182.5 mg ÷ 2 = 91.25 mg.

Step 4 is to convert the dose from mg to mL using the concentration of the medication. 91.25 mg ÷ (200 mg/5 mL) = 91.25 ÷ 40 = 2.3 mL per dose. The answer is 2.3 mL.

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A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is ["2.3"]

Explanation

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A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum.
Which action should the nurse perform first?