A nurse is assisting in caring for a client who was just admitted with partial-thickness burns to their upper torso. Which of the following actions should the nurse take first?

Use aseptic technique during wound care for the client.

Obtain the client's oxygen saturation levels.

Check the client's WBC count.

Regulate IV fluids to maintain the client's urinary output.

Answer and Explanation

The Correct Answer is B

A. Use aseptic technique during wound care for the client. While using aseptic technique is essential for preventing infection during wound care, it is not the immediate priority upon admission. The nurse must first assess the client's airway and oxygenation status.
B. Obtain the client's oxygen saturation levels. Obtaining the client's oxygen saturation levels is the priority action. Clients with burns, especially those affecting the upper torso, may have compromised airway patency or inhalation injury. Assessing oxygen saturation is crucial for determining the need for supplemental oxygen or further airway interventions.
C. Check the client's WBC count. Checking the client's white blood cell (WBC) count is important for evaluating potential infection and overall health status, but it is not an immediate priority in the acute phase of burn management. The nurse should focus first on airway and respiratory assessment.
D. Regulate IV fluids to maintain the client's urinary output. Regulating IV fluids to maintain urinary output is an important action in managing burn clients, as fluid resuscitation is critical. However, it should be done after ensuring the client's airway and oxygenation are stable, as inadequate oxygenation could complicate fluid resuscitation efforts.

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Correct Answer is C

Explanation

A. "Request that the nurses show their nursing license prior to removing your newborn from the room." While it's important to ensure that only authorized personnel handle the newborn, asking for nursing licenses is not practical and may not be feasible in a busy clinical environment. Instead, parents should be encouraged to verify the identity of staff based on hospital protocols.
B. "Leave your newborn in the bassinet in your room while you use the bathroom." Leaving the newborn unattended, even in the bassinet, is not advisable. Parents should take their newborn with them if possible or ask for help from staff to ensure the baby's safety while they are away.
C. "Alert the staff if any of your newborn's identification bands are missing." Alerting staff about missing identification bands is crucial for the safety of the newborn. Identification bands help prevent abductions and ensure that the correct infant is returned to the right mother. Parents should be vigilant and report any issues immediately.
D. "Carry your newborn back to the nursery in your arms when you need to rest." Carrying the newborn back to the nursery is not recommended for safety reasons. If the parent needs to rest, they should ask the staff to take the baby to the nursery instead, allowing for proper handling and minimizing the risk of falls or accidents.

A. Client reports the urge to defecate B. There is increased bloody show C. cervix is 10 cm dilated D. Contractions strong on palpation E. Temperature 39.1° C (102.4" F) F. Heart rate 110/min

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

Explanation

Rationale for Correct Options:

Urge to defecate occurs as the fetal head descends further into the birth canal, putting pressure on the rectum and perineum. This is a common sign of the second stage of labor, indicating that the client is nearing delivery.
Increased bloody show results from cervical dilation and effacement as the capillaries in the cervix rupture. A greater amount of blood-tinged mucus is expected as labor progresses, particularly in the transition phase and early second stage.
Cervix 10 cm dilated confirms that the client has reached full cervical dilation, which is required for the second stage of labor to begin. Complete dilation allows for the passage of the fetus through the birth canal.
Contractions strong on palpation indicate effective uterine activity, which is necessary for fetal descent and expulsion. Strong contractions help in moving the baby downward and increasing pressure on the cervix.

Rationale for Incorrect Options:

A heart rate of 110/min is elevated compared to the client’s earlier readings (90/min at 0830, 110/min at 0845) and may indicate maternal stress or exertion from labor pain. While mild increases in maternal heart rate are expected during labor, tachycardia above 110/min warrants further evaluation, particularly in the presence of fever.
Temperature of 39.1°C (102.4°F). This temperature is abnormally high and suggests infection, such as chorioamnionitis, especially considering the prolonged rupture of membranes since 1900 the previous night. Normal maternal temperature may rise slightly during labor due to exertion, but fever above 38°C (100.4°F) is concerning and requires medical attention.

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A nurse is assisting in caring for a client who was just admitted with partial-thickness burns to their upper torso. Which of the following actions should the nurse take first?

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