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 A
Explanation
Choice A rationale
Continuous fetal monitoring is expected because it provides ongoing information about the fetal heart rate and contractions, which is crucial after an eclamptic seizure.
Choice B rationale
Antenatal steroid administration is not the immediate intervention post-seizure but is given to enhance fetal lung maturity if preterm delivery is anticipated.
Choice C rationale
Expectant management protocol is incorrect because active management is required in the case of an eclamptic seizure to stabilize the mother and fetus.
Choice D rationale
Umbilical artery blood flow analysis might be part of a comprehensive evaluation but is not the immediate priority post-eclampsia seizure.
Correct Answer is B
Explanation
Choice A rationale
Feeding the newborn water during the procedure is incorrect because water does not provide effective pain relief during procedures.
Choice B rationale
Placing the newborn's arms and legs in flexion and close to the midline of the torso is correct as this position, known as facilitated tucking, provides comfort and can help reduce pain.
Choice C rationale
Placing the newborn supine during the procedure is incorrect because it does not provide any specific pain relief benefits.
Choice D rationale
Elevating the newborn's head during the procedure is not specifically related to pain relief but is more about positioning for ease of access. .
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