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A nurse is assisting in the care of a client who is in active labor and is to undergo an amniotomy. Which of the following actions should the nurse take? (Move the steps into the box, placing them in the order of performance. Use all the steps.)

Obtain a baseline reading of the FHR and contraction pattern.

Document the procedure in the electronic medical record.

Pass the sterile hook to the provider.

Position the client with a rolled towel under her hips

Check the fluid for color, odor, and consistency

Answer and Explanation

The Correct Answer is A,D,C,E,B

A. Obtain a baseline reading of the FHR and contraction pattern.
- Establishing a baseline of fetal heart rate (FHR) and contraction pattern is crucial to assess for any immediate changes following the amniotomy.
D. Position the client with a rolled towel under her hips.
- Positioning the client with a rolled towel under her hips helps to relieve pressure on the vena cava, improve uterine blood flow, and optimize fetal positioning.
C. Pass the sterile hook to the provider.
- The sterile hook is used to break the amniotic sac, and the nurse should pass it to the provider during the procedure.
E. Check the fluid for color, odor, and consistency.
- After the amniotomy, the nurse should assess the amniotic fluid for color (should be clear), odor (should be odorless), and consistency to check for any signs of meconium or infection.
B. Document the procedure in the electronic medical record.
- The nurse should document the amniotomy procedure and any findings (e.g., FHR changes, amniotic fluid assessment) in the medical record after the procedure has been completed.

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Correct Answer is C

Explanation

A. Eating turkey sausage for breakfast is incorrect. Processed meats, including turkey sausage, are high in sodium and should be avoided in a low-sodium diet. Even "healthier" alternatives can contain significant amounts of added salt.

B. Putting ketchup on hot dogs is incorrect. Ketchup and hot dogs are both high in sodium, making them poor choices for a client managing hypertension.

C. Using frozen vegetables rather than canned is correct. Canned vegetables often contain added sodium for preservation, while frozen vegetables typically have little to no added salt, making them a healthier option.

D. Using store-bought spaghetti sauce is incorrect. Many commercial pasta sauces contain high levels of sodium, which can contribute to increased blood pressure. A low-sodium alternative, such as homemade sauce with fresh ingredients, would be a better choice.

A. You wish you were no longer alive? B. "It is common for people who have a terminal illness to feel that way." C. "Why do you wish you weren't alive any longer?" D. "We should talk about the treatment plan your provider has suggested."

Correct Answer is B

Explanation

A. You wish you were no longer alive?: This response might sound accusatory and may invalidate the client's feelings. The nurse should express empathy and understanding instead of making the client feel misunderstood.

B. "It is common for people who have a terminal illness to feel that way.": This response validates the client's feelings by acknowledging the emotional distress that often accompanies a terminal illness. It normalizes the experience without minimizing it and opens the door for further discussion.

C. "Why do you wish you weren't alive any longer?": While this response is direct, it might sound too probing and may feel intrusive or dismissive of the client's emotional state. A softer, more empathetic approach is usually preferred.

D. "We should talk about the treatment plan your provider has suggested.": While discussing treatment plans is important, this response may deflect the client's emotional distress and shift the focus away from their immediate emotional needs. The nurse should first address the emotional aspect before discussing treatment.

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A nurse is assisting in the care of a client who is in active labor and is to undergo an amniotomy. Which of the following actions should the nurse take? (Move the steps into the box, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about a low-sodium diet with a client who has hypertension. Which of the following statements by the client indicates an understanding of the instructions?

Correct Answer is C

Explanation

A nurse is caring for a client who has a terminal illness. The client states, "I wish I would die now." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement first?

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A nurse is assisting in the care of a client who is in active labor and is to undergo an amniotomy. Which of the following actions should the nurse take? (Move the steps into the box, placing them in the order of performance. Use all the steps.)

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