A nurse is assisting in the care of a client who is admitted for complications associated with intrauterine fetal demise and becomes unresponsive.
Which of the following actions should the nurse take first?
Obtain a set of vital signs.
Assess vaginal bleeding.
Call the rapid response team.
Notify the provider.
The Correct Answer is C
Choice A rationale
Obtaining a set of vital signs is important but not the first action. Assessing responsiveness and activating emergency response takes precedence to ensure prompt intervention.
Choice B rationale
Assessing vaginal bleeding is necessary, but it should follow immediate life-saving actions like calling the rapid response team.
Choice C rationale
Calling the rapid response team should be the first action as it mobilizes a team of healthcare professionals to provide immediate advanced care, which is crucial in an unresponsive patient.
Choice D rationale
Notifying the provider is essential, but it should be done after the rapid response team is activated to ensure timely intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While ibuprofen can reduce general inflammation, its primary use in the postpartum period is not aimed at reducing swelling in the extremities, making this a less relevant outcome for the medication's effectiveness.
Choice B rationale
Ibuprofen is an effective analgesic for reducing discomfort from uterine contractions, known as afterpains, which occur as the uterus involutes post-delivery. A decrease in this type of discomfort indicates the medication has achieved its desired effect.
Choice C rationale
Ibuprofen does not have an effect on milk production; therefore, a decrease in milk production is not an expected or desired outcome of administering this medication to a postpartum client.
Choice D rationale
Ibuprofen is not intended to reduce lochia or the passage of clots. These are normal postpartum processes, and their reduction would not be an expected outcome of ibuprofen administration.
Correct Answer is C
Explanation
Choice A rationale
2 units is insufficient to bring down a blood sugar level of 152 mg/dL adequately. According to the sliding scale, 2 units typically lower blood sugar by 50-60 mg/dL, which might not be enough for this level.
Choice B rationale
3 units might reduce blood sugar by approximately 75-90 mg/dL. However, this reduction may not be adequate to bring the blood sugar level within the target range, depending on individual response to insulin.
Choice C rationale
4 units of insulin are suitable for a blood sugar level of 152 mg/dL. Generally, 1 unit of insulin lowers blood sugar by 30-50 mg/dL. Administering 4 units should ideally lower the blood sugar level to the desired range.
Choice D rationale
5 units of insulin could result in an excessive drop in blood sugar levels. It could reduce the blood sugar level by 150-200 mg/dL, which might risk hypoglycemia, making it an unsuitable choice for a blood sugar level of 152 mg/dL.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.