A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?

Offer the client a sitz bath.

Insert a urinary catheter.

Assist the client to the bathroom.

Pour warm water over the client's perineum.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Offering the client a sitz bath may provide some relief, but it does not address the underlying issue of bladder distention. The priority is to address the bladder distention directly.

Choice B rationale:
Inserting a urinary catheter is not the first-line intervention for bladder distention after vaginal birth. Catheterization carries a risk of infection and trauma, so it should only be done if other interventions are not effective.

Choice C rationale:
Assisting the client to the bathroom is the first action the nurse should take. Bladder distention can occur after birth due to the pressure on the bladder during labour and birth. Encouraging the client to empty her bladder will relieve the distention and promote comfort.

Choice D rationale:
Pouring warm water over the client's perineum might provide some comfort, but it does not address the bladder distention itself.

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Correct Answer is C

Explanation

The correct answer is choice C: Verify that informed consent is obtained prior to administration. Choice A rationale: Placing the client in a semi-Fowler’s position is not specifically related to the administration of dinoprostone. This position is often used post-administration to promote comfort and labor progression, but it is not a required action prior to the administration of dinoprostone. Choice B rationale: Instructing the client to avoid urinary elimination until after administration is not necessary. There is no evidence to suggest that retaining urine affects the efficacy or safety of dinoprostone administration. Choice C rationale: Verifying that informed consent is obtained prior to administration is crucial. Dinoprostone, like any medication used to induce labor, carries potential risks and side effects. It is essential that the client is informed about these risks and consents to the procedure before the medication is administered. Choice D rationale: Allowing the medication to reach room temperature prior to administration is not a standard requirement for dinoprostone inserts. Medications have specific storage and administration guidelines that should be followed according to the manufacturer’s instructions and facility protocols.

A. Decrease maintenance IV solution infusion rate. B. Place the client in a lateral position. C. Administer oxygen via face mask at 2 L/min. D. Administer misoprostol 25 mcg vaginally.

Correct Answer is B

Explanation

Choice A rationale:

Decreasing the maintenance IV solution infusion rate is not the appropriate action for addressing late decelerations of the fetal heart rate. Late decelerations are a concerning sign during labor, indicating possible fetal distress. This can be caused by inadequate oxygenation of the fetus, and reducing IV fluids would not directly address this issue.

Choice B rationale:

Placing the client in a lateral (side-lying) position is the correct action when late decelerations are observed. This position helps to improve uteroplacental blood flow and can relieve pressure on the inferior vena cava, thus increasing oxygen supply to the fetus.

Choice C rationale:

Administering oxygen via face mask at 2 L/min is not the priority action in response to late decelerations. While oxygen may be beneficial in certain situations, it is not the initial intervention for addressing fetal heart rate decelerations.

Choice D rationale:

Administering misoprostol 25 mcg vaginally is not appropriate for addressing late decelerations. Misoprostol is a medication used for cervical ripening and induction of labor, but it does not directly address fetal heart rate changes.

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A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor tracing. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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