A client who is multiparous at 38-weeks gestation is admitted to labor and delivery with contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the practical nurse (PN) hears a baby crying. Which action should the PN take first?
Turn on the infant warmer.
Push the call light for help.
Notify a healthcare provider.
Inspect the client's perineum.
The Correct Answer is B
A. Turning on the infant warmer is a necessary step but comes after confirming that the infant is actually being born. The immediate priority is to assess the situation to ensure the health and safety of both the mother and baby.
B. Pushing the call light alerts other healthcare professionals that immediate assistance is needed. Given that the baby is crying, it suggests that the birth may have occurred unexpectedly, and help is required to manage the situation safely.
C. Notifying a healthcare provider is essential, but the PN should first verify the situation to provide accurate information and context for the healthcare provider's arrival.
D. Inspecting the perineum is important to assess for any complications or to check if delivery has occurred. However, this action should follow ensuring that help is called and that the environment is safe for both mother and baby. The primary focus should be on ensuring that assistance is on the way before performing an assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Eliminating citrus drinks is not specifically related to preventing dumping syndrome. While citrus drinks might irritate the stomach, the main dietary consideration for dumping syndrome is the timing of fluid intake.
B. Consuming fluids 30 minutes to one hour after meals helps prevent dumping syndrome. Drinking fluids too close to meal times can increase the risk of dumping syndrome by accelerating gastric emptying.
C. Increasing the intake of carbonated fluids after meals is not recommended for preventing dumping syndrome. Carbonated drinks can exacerbate symptoms rather than help prevent them.
D. Avoiding caffeinated beverages can be part of general dietary recommendations, but it is not the primary measure to prevent dumping syndrome. The timing of fluid intake relative to meals is more crucial.
Correct Answer is C
Explanation
A. Feeling for a carotid pulse is part of the assessment process but is not the first step in responding to an unresponsive client. Immediate action to summon emergency help is the priority.
B. Bringing a glucometer to the room is not appropriate at this stage. While checking blood glucose might be necessary, the first step is to get emergency assistance.
C. Obtaining emergency help is the most critical first step when encountering an unresponsive client. Emergency help ensures that appropriate interventions are initiated promptly.
D. Checking the blood pressure is part of a complete assessment but is not the most urgent action. The priority is to call for emergency assistance rather than performing further assessments.
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