A nurse is caring for a client who is at 38 weeks of gestation, is in active labor, and has ruptured membranes. Which of the following actions should the nurse take?
Initiate fundal massage.
Apply a fetal heart rate monitor.
Insert an indwelling urinary catheter.
Initiate an oxytocin IV infusion.
The Correct Answer is B
Rationale:
A. Initiate fundal massage: Fundal massage is performed after delivery to prevent or manage uterine atony and postpartum hemorrhage. It is not appropriate during active labor, especially before the birth of the fetus.
B. Apply a fetal heart rate monitor: After rupture of membranes, there is an increased risk of umbilical cord prolapse or fetal distress. Continuous fetal monitoring is essential to assess fetal well-being and detect complications promptly.
C. Insert an indwelling urinary catheter: While catheterization may be done later, especially before epidural placement or cesarean delivery, it is not the most urgent action. It does not address immediate risks associated with ruptured membranes.
D. Initiate an oxytocin IV infusion: Oxytocin is used to augment or induce labor, but should not be started without first assessing fetal status. Fetal monitoring is necessary to establish a baseline before initiating uterotonic agents.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Fentanyl: Fentanyl is a potent opioid typically reserved for severe, acute, or chronic pain such as in surgical or cancer-related conditions. It is not commonly used for moderate pain in stable orthopedic cases like a simple fracture.
B. Aspirin: Aspirin is a mild analgesic and anti-inflammatory. It may help with mild pain but is inadequate for moderate pain rated 7/10. Additionally, its antiplatelet effects can increase bleeding risk, especially post-trauma.
C. Hydrocodone: Hydrocodone is an opioid analgesic appropriate for managing moderate to severe pain, such as that caused by a fracture. It is commonly used in combination with acetaminophen and is suitable for a pain rating of 7/10.
D. Acetaminophen: Acetaminophen is effective for mild to moderate pain but may not provide sufficient relief for pain rated at 7/10. It is often used adjunctively but would not be the primary choice in this scenario.
Correct Answer is B
Explanation
Rationale:
A. 2+ deep-tendon reflexes: This is a normal reflex response and indicates that the client is not yet experiencing magnesium toxicity, which would be marked by decreased or absent reflexes. It does not require immediate intervention.
B. Respiratory rate 10/min: A respiratory rate below 12/min is a critical indicator of magnesium toxicity. Magnesium sulfate can depress the central nervous system, leading to respiratory depression, which can be life-threatening and demands immediate action.
C. Urinary output 35 mL/hr: Although slightly below the typical threshold of 30 mL/hr for safe magnesium clearance, this finding is still adequate. It should be monitored closely but is not the most urgent concern at this moment.
D. 3+ pedal edema: Pedal edema is common in preeclampsia due to fluid retention and vascular changes. While notable, it does not take priority over signs of potentially life-threatening respiratory depression.
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