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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A) Incorrect - The umbilical area is not a typical location for auscultating fetal heart tones.
B) Incorrect - The suprapubic area is not a common location for auscultating fetal heart tones.
C) Correct - At 12 weeks of gestation, the nurse would typically auscultate the fetal heart tones above the left iliac crest, which is in the lower abdomen. This is where the uterus is located at this stage of pregnancy.
D) Incorrect - Auscultating below the liver border on the right abdomen is not a standard practice for fetal heart tone assessment.
Correct Answer is B
Explanation
A) Incorrect- Scheduling a routine 1-month appointment is not appropriate given the elevated glucose value. A 1-hour glucose screening test value of 130 mg/dL indicates an elevated glucose level, which suggests the need for further testing to confirm or rule out gestational diabetes.
B) Correct - An elevated glucose value on the initial screening test requires confirmation through a more comprehensive test, such as the 3-hour oral glucose tolerance test.
C) Incorrect- Home glucose monitoring might be indicated for gestational diabetes but is not the next step after an elevated 1-hour glucose screening test.
D) Incorrect- Repeating the 1-hour glucose test in 1 week is not necessary; if the initial test is elevated, further testing is required.
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.