A nurse admits a woman who is 38 weeks gestation and has ruptured membranes.
The nurse determines that the amniotic fluid is clear and odorless.
Besides notifying the provider, which of the following is the appropriate first nursing action?

Allow the client to ambulate in the hallway to initiate labor.

Encourage oral fluids and administer an antipyretic medication.

Administer glucocorticoids intramuscularly.

Check the client's temperature every 2 hours.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Allowing the client to ambulate in the hallway to initiate labor is not the first appropriate action because it does not address the immediate need to monitor the client's temperature. Ambulation can be considered after ensuring there are no signs of infection or other complications.

Choice B rationale

Encouraging oral fluids and administering an antipyretic medication is not the initial priority. While hydration is important, the primary focus should be on monitoring for signs of infection, which can be indicated by changes in temperature.

Choice C rationale

Administering glucocorticoids intramuscularly is typically for promoting fetal lung maturity in cases of preterm labor, not for term pregnancies at 38 weeks. It does not address the immediate need to monitor maternal temperature after membrane rupture.

Choice D rationale

Checking the client's temperature every 2 hours is crucial to monitor for signs of infection, such as chorioamnionitis, which can occur after membrane rupture. Early detection of fever can prevent complications for both mother and baby.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Administer antihypertensive medication as prescribed - The client's blood pressure is elevated, and managing hypertension is crucial to prevent complications.

B. Initiate continuous fetal monitoring - The client is experiencing symptoms that could indicate preeclampsia, and continuous monitoring is essential to assess fetal well-being.

C. Monitor for signs of magnesium toxicity - Given the client's symptoms and lab results, monitoring for magnesium toxicity is important, especially if magnesium sulfate is being used for seizure prophylaxis.

D. Perform a vaginal exam to assess cervical status - This intervention is not a priority at this moment given the client's condition and the need to avoid unnecessary interventions that could cause stress or complications.

E. Assess for signs of placental abruption - Although the client denies vaginal bleeding, it's important to monitor for any signs of placental abruption due to her symptoms and hypertension.

A. Administering epinephrine before the procedure. B. Positioning client on her back prior to the procedure. C. Having her eat a carbohydrate snack prior to the procedure. D. Administering a bolus of 0.9% Normal saline IV fluid before the procedure.

Correct Answer is D

Explanation

Choice A rationale

Administering epinephrine before the procedure is not standard practice to prevent hypotension associated with epidurals. Epinephrine is used in emergency situations to treat severe allergic reactions or cardiac arrest, not for preventing epidural-induced hypotension.

Choice B rationale

Positioning the client on her back prior to the procedure is not recommended, as it can exacerbate hypotension due to compression of the inferior vena cava by the gravid uterus. This position can decrease venous return to the heart and reduce cardiac output.

Choice C rationale

Having the patient eat a carbohydrate snack prior to the procedure is not a standard intervention to prevent hypotension during an epidural. Dietary intake does not directly prevent the vasodilatory effects of the epidural anesthesia.

Choice D rationale

Administering a bolus of 0.9% Normal saline IV fluid before the procedure is the correct intervention to prevent hypotension. Preloading with IV fluids increases intravascular volume, counteracting the vasodilation and potential drop in blood pressure caused by the epidural anesthesia. .

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A nurse admits a woman who is 38 weeks gestation and has ruptured membranes.The nurse determines that the amniotic fluid is clear and odorless.Besides notifying the provider, which of the following is the appropriate first nursing action?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 34-year-old female client who is at 34 weeks of gestation in the labor and delivery unit. Below are the exhibits and the questions based on the client's condition. Exhibits What are the priority nursing interventions for this client? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

A primigravida dilated to 5 cm will receive an epidural for pain.Which of the following interventions will help prevent hypotension in the patient?

Correct Answer is D

Explanation

A nurse is caring for a client who is in active labor and notes persistent late decelerations on the fetal monitor.Which of the following are the priority nursing actions? (Select all that apply.)

The nurse is aware that which of the following magnesium sulfate levels should be reported to the MD and is most likely to result in toxicity?

A nurse admits a woman who is 38 weeks gestation and has ruptured membranes.The nurse determines that the amniotic fluid is clear and odorless.Besides notifying the provider, which of the following is the appropriate first nursing action?

Using Leopold's Maneuvers, the fetus is found to be with its occiput facing toward the left maternal spine.The mother is complaining of increased back labor pain.The nurse knows that the fetus is in which position?

A nurse is caring for a 34-year-old female client who is at 34 weeks of gestation in the antepartum unit. Exhibits Complete the following sentence using the list of options. Sentence: The priority intervention for the client is to dropdown and dropdown.

A nurse is caring for a 34-year-old female client who is at 34 weeks of gestation in the antepartum unit. Exhibits What is the most appropriate action the nurse should take next?

A nurse admits a woman who is 38 weeks gestation and has ruptured membranes.
The nurse determines that the amniotic fluid is clear and odorless.
Besides notifying the provider, which of the following is the appropriate first nursing action?