A nurse is assisting in the care of a client who is in labor and whose membranes ruptured 6 hr ago. Which of the following is an appropriate nursing intervention for this client?
Monitor for infection.
Position the client supine.
Obtain consent for a cesarean birth.
Prepare for a forceps delivery.
The Correct Answer is A
A) Correct - Monitoring for infection is an appropriate nursing intervention for a client whose membranes have ruptured, as there is an increased risk of infection after the amniotic sac has ruptured for an extended period.
B) Incorrect- Positioning the client supine is not generally recommended for a client in labor, especially if the client's membranes have ruptured.
C) Incorrect- Obtaining consent for a cesarean birth is not indicated solely based on the information provided.
D) Incorrect- Preparing for a forceps delivery is not indicated solely based on the information provided.
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Related Questions
Correct Answer is C
Explanation
A) Incorrect- Oxytocin is not typically administered during a nonstress test.
B) Incorrect- A nonstress test is used to assess fetal well-being and does not indicate Down syndrome.
C) Correct - A lateral tilt position (usually left lateral tilt) is recommended during a nonstress test to prevent compression of the vena cava and maintain proper blood flow to the uterus, which can optimize fetal heart rate monitoring.
D) Incorrect- NPO status is not typically required for a nonstress test. Nonstress tests are non-invasive and do not involve fasting.
Correct Answer is A
Explanation
A) Correct - Chronic hypertension is a significant risk factor for developing preeclampsia during pregnancy. Preeclampsia is characterized by high blood pressure and organ damage, typically occurring after 20 weeks of pregnancy.
B) Incorrect- Maternal age of 30 years is not a specific risk factor for preeclampsia.
However, maternal age over 40 is considered a risk factor.
C) Incorrect- A prepregnancy BMI of 19 falls within the healthy weight range and is not typically associated with an increased risk of preeclampsia.
D) Incorrect- Having a third pregnancy is not inherently a strong risk factor for preeclampsia. Women experiencing their first pregnancy are at a slightly higher risk.
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