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 B
Explanation
Choice A rationale
One parity indicates one delivery at a viable gestational age, which is not accurate for this client.
Choice B rationale
Two parity is correct as the client has delivered twins (considered one parity) at 36 weeks, which counts as one delivery at a viable gestational age.
Choice C rationale
Three parity is incorrect because the previous pregnancies did not result in three separate viable deliveries.
Choice D rationale
Four parity is incorrect as the client’s history includes one viable delivery (twins) and does not account for four separate viable births. .
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