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
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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Related Questions
Correct Answer is B
Explanation
A. Candidiasis. This is a common fungal infection, often caused by Candida albicans. It is not a reportable disease to public health authorities because it is not typically considered a public health threat.
B. Chlamydia. Chlamydia is a nationally notifiable infectious disease due to its high prevalence and potential for serious complications such as infertility. Providers are required to report it to the state health department to aid in public health surveillance and control efforts.
C. Herpes simplex virus. While herpes is a common sexually transmitted infection, it is not currently on the national notifiable disease list and is not required to be routinely reported to public health agencies.
D. Human papillomavirus (HPV). HPV is widespread and associated with cervical cancer, but routine HPV infection is not reportable. However, certain types of cancer caused by HPV may be included in cancer registries.
Correct Answer is B
Explanation
A. Calories. Significant increases in caloric intake are not necessary during the first trimester. Most women do not require additional calories until the second and third trimesters, when fetal growth accelerates.
B. Folate. Folate (or folic acid) is crucial during early pregnancy, particularly in the first trimester, to prevent neural tube defects such as spina bifida. Women are advised to increase folate intake before conception and during early pregnancy.
C. Calcium. Calcium needs increase later in pregnancy when the fetus's bone development intensifies. While important throughout pregnancy, calcium is not the most critical nutrient to increase specifically in the first trimester.
D. Protein. Protein is essential for fetal growth, but increased protein needs become more important in the second and third trimesters when fetal tissue development peaks. Early pregnancy focuses more on folate supplementation for neural development.
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