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 an oxytocin IV infusion

Apply a fetal heart rate monitor.

Initiate fundal massage.

Insert an indwelling urinary catheter

Answer and Explanation

The Correct Answer is B

A. Initiate an oxytocin IV infusion. Oxytocin may be used to augment labor, but it should not be started immediately without first assessing maternal and fetal well-being. Continuous monitoring is necessary before initiating any uterotonic agent.
B. Apply a fetal heart rate monitor. After rupture of membranes, assessing the fetal heart rate is critical to detect signs of umbilical cord prolapse or fetal distress. Continuous electronic fetal monitoring helps evaluate the baby's response to labor.
C. Initiate fundal massage. Fundal massage is performed after delivery of the placenta to help contract the uterus and reduce postpartum bleeding. It is not appropriate during active labor.
D. Insert an indwelling urinary catheter. A catheter may be placed if necessary during labor, especially before epidural anesthesia, but it is not the immediate priority following membrane rupture. Fetal monitoring takes precedence.

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Correct Answer is A

Explanation

A. Weak femoral pulses. Coarctation of the aorta is a congenital narrowing of the aorta, which leads to reduced blood flow to the lower extremities, resulting in weak or absent femoral pulses—a hallmark finding of this condition.
B. Increased intracranial pressure. This is not directly associated with coarctation of the aorta. While severe hypertension can lead to neurologic symptoms, increased ICP is not a typical or early finding.
C. Upper extremity hypotension. The condition causes hypertension in the upper extremities and hypotension in the lower extremities due to the location of the narrowing. Upper extremity hypotension would be an unexpected finding.
D. Frequent nosebleeds. While nosebleeds may occur in older children or adults with uncontrolled hypertension, they are not an expected finding in infants with coarctation of the aorta.

A. "How long have you struggled with your weight?" B. "Let's discuss some weight loss strategies that might work for you." C. "It sounds like you're saying that you feel uncomfortable around others." D. "Have you always felt uncomfortable being overweight?"

Correct Answer is C

Explanation

A. "How long have you struggled with your weight?" While this may provide background information, it shifts the focus to the client's weight history rather than validating their current emotional experience and distress.
B. "Let's discuss some weight loss strategies that might work for you." This response prematurely shifts to problem-solving and weight management without first addressing the client’s emotional needs or acknowledging their feelings of embarrassment and vulnerability.
C. "It sounds like you're saying that you feel uncomfortable around others." This is a therapeutic, reflective response that validates the client’s feelings and encourages them to express more about their emotional experience, fostering trust and emotional support.
D. "Have you always felt uncomfortable being overweight?" This question may come across as judgmental and focuses too much on the client's body image history rather than their current emotional experience, potentially worsening feelings of shame.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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