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 D

Explanation

A. "After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast." The breast is rarely fully emptied during a feeding. Infants should be allowed to feed on one side until they naturally release it, ensuring they receive the nutrient-rich hindmilk.
B. "Manually expressing my milk will decrease my milk supply." Manual expression, like breastfeeding, stimulates milk production. Regularly removing milk from the breasts actually helps maintain or increase supply, especially during periods of engorgement or separation.
C. “My baby should always start on the same breast when feeding.” Alternating the starting breast with each feeding ensures even stimulation and drainage of both breasts. Always starting on the same side could lead to engorgement or reduced supply in the unused breast.
D. “The more my baby is at the breast sucking the more milk I will produce.” Breast milk production is based on a supply and demand mechanism. The more frequently and effectively the baby nurses, the more milk the body is signaled to produce.

A. Match the client's blood type with the type and cross match specimen. B. Confirm the provider's prescription matches the number on the blood component. C. Ask the client to state his blood type and the date of the blood donation. D. Ensure that the client's identification band matches the number on the blood unit.

Correct Answer is D

Explanation

A. Match the client's blood type with the type and cross match specimen. While type and crossmatch are important for allogeneic transfusions, an autologous transfusion uses the client’s own previously donated blood, so this is not the primary method for identification.
B. Confirm the provider's prescription matches the number on the blood component. Although important, this step alone does not verify the client’s identity. The nurse must also confirm the blood unit matches the correct client.
C. Ask the client to state his blood type and the date of the blood donation. Client recall is not a reliable form of identification for transfusion safety, as it is prone to error or misunderstanding.
D. Ensure that the client's identification band matches the number on the blood unit. This is the correct and safest method to confirm identity before administering an autologous blood product. It ensures the blood product is matched to the correct patient.

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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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