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. Provide a verbal report of the client's condition to the paramedic performing the transfer. This is an appropriate and secure method for communicating essential health information directly involved in the client’s care. It ensures continuity of care while maintaining confidentiality.
B. Email the client's health information to the facility in an unencrypted file. Sending health information via unencrypted email violates HIPAA guidelines and poses a risk to client confidentiality due to potential unauthorized access.
C. Discuss the client's response to the transfer with another staff nurse. Unless the staff nurse is directly involved in the client’s care, this would be a breach of confidentiality. Personal health information should only be shared on a need-to-know basis.
D. Fax the client's name and identifiable information to the rehabilitation facility. Faxing is permissible only when appropriate safeguards are in place. However, faxing identifiable information without confirming the recipient or using secure protocols can risk a confidentiality breach.

A. Silence the bed alarm when visitors are at the client's bedside. B. Establish an elimination schedule for the client. C. Raise all four bed rails on the client's bed. D. Allow the client to walk unassisted near the nursing station

Correct Answer is B

Explanation

A. Silence the bed alarm when visitors are at the client's bedside. Bed alarms are a critical safety device for clients on fall precautions and should never be silenced when the client is in bed, regardless of visitors. Alarms alert staff if the client attempts to get up unsafely.
B. Establish an elimination schedule for the client. A regular toileting schedule helps reduce the risk of falls by preventing unassisted attempts to get out of bed to use the bathroom. This proactive approach supports both safety and comfort.
C. Raise all four bed rails on the client's bed. Raising all four rails is considered a form of restraint and can actually increase the risk of injury if the client attempts to climb over them. Two rails up is generally acceptable for support and safety.
D. Allow the client to walk unassisted near the nursing station. Clients on fall precautions should always be supervised or assisted during ambulation to prevent accidents, even when close to staff. Being near the nursing station does not eliminate the risk.

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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 B

Explanation

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