A nurse is caring for a client who is experiencing an amniotic fluid embolism during labor.
Which of the following actions should the nurse take?
Plan to administer ephedrine IV.
Assist the client to empty their bladder.
Assess for the presence of clonus.
Prepare to initiate cardiopulmonary resuscitation.
The Correct Answer is D
Choice A rationale:
Administering ephedrine IV is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. Ephedrine is typically used to treat hypotension during spinal anesthesia, not amniotic fluid embolism.
Choice B rationale:
Assisting the client to empty their bladder is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. While bladder care is important, it is not the priority in this situation.
Choice C rationale:
Assessing for the presence of clonus is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. Clonus is typically assessed in clients with preeclampsia or eclampsia, not amniotic fluid embolism.
Choice D rationale:
Preparing to initiate cardiopulmonary resuscitation is the appropriate action for a client experiencing an amniotic fluid embolism during labor. Amniotic fluid embolism can lead to cardiovascular collapse, therefore, immediate resuscitation measures should be prepared15.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A feeling of vaginal fullness is not a therapeutic effect of oxytocin. It could indicate a vaginal hematoma or retained placental fragments.
Choice B rationale:
The client’s fundus is firm and midline. This is the expected therapeutic effect of oxytocin. It stimulates uterine contractions to prevent postpartum hemorrhage.
Choice C rationale:
Saturating a perineal pad in 1 hr could indicate postpartum hemorrhage, which is not a therapeutic effect of oxytocin.
Choice D rationale:
The client’s umbilical cord lengthening is not related to oxytocin administration. It could indicate placental separation.
Correct Answer is B
Explanation
Choice A rationale:
A previous delivery at 37 weeks gestation is considered full term, not a risk factor for preterm delivery.
Choice B rationale:
A previous cervical cerclage indicates a history of cervical insufficiency, which is a risk factor for preterm delivery.
Choice C rationale:
A previous reactive non-stress test is a positive sign of fetal well-being, not a risk factor for preterm delivery.
Choice D rationale:
A previous delivery of a newborn weighing 2.5 kg (5.5 Ib) is within the normal range, not a risk factor for preterm delivery.
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