The nurse determines the need to perform further assessment based on the client's situation.Select the 2 actions that the nurse should perform immediately.
Perform a vaginal exam.
Take vital signs.
Palpate the bladder.
Examine the amniotic fluid.
Dipstick urine for protein and ketones.
Correct Answer : A,B
Choice A rationale
Performing a vaginal exam is crucial in assessing the progress of labor and the condition of the cervix, particularly if the client has reported symptoms such as contractions, bleeding, or fluid leakage. It helps determine if the client is in active labor or if there are any complications requiring immediate intervention.
Choice B rationale
Taking vital signs is essential to assess the client's overall health and identify any signs of distress or complications. Vital signs provide critical information about the client's cardiovascular and respiratory status, which is important for immediate clinical decision-making.
Choice C rationale
Palpating the bladder is important in assessing for bladder distention, which can impede labor progress or cause discomfort. However, it is not the immediate priority compared to assessing labor progress and overall health status.
Choice D rationale
Examining the amniotic fluid is important for determining its characteristics, which can provide information about the fetal well-being. However, this action is secondary to performing a vaginal exam and taking vital signs in the immediate assessment.
Choice E rationale
Dipstick urine for protein and ketones helps in assessing for preeclampsia or gestational diabetes, but it does not address the immediate need to assess labor progress and the client's overall health status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Drinking water is not necessary before a triple screen analysis. This test does not require a full bladder.
Choice B rationale
The left lateral tilt position is typically used to prevent supine hypotensive syndrome in pregnant women during ultrasounds, not for a blood draw.
Choice C rationale
A triple screen analysis involves drawing blood from the mother to test for specific markers that indicate the risk of certain fetal abnormalities. Blood sampling is necessary for the analysis.
Choice D rationale
Applying an external fetal monitor is unrelated to a triple screen analysis, which focuses on maternal blood markers rather than fetal heart rate monitoring.
Correct Answer is B
Explanation
Choice A rationale: Increasing the infusion rate of magnesium sulfate without medical approval is not appropriate. The prescribed rate should be followed unless the provider orders a change.
Choice B rationale: Assessing the client’s deep tendon reflexes and respiratory rate before administering magnesium sulfate is crucial. Magnesium sulfate can depress the central nervous system and respiratory function, so baseline assessments are necessary to identify any adverse effects early.
Choice C rationale: Stopping the infusion for variable decelerations is not the initial step. Variable decelerations may need to be addressed, but it is not the priority action before starting magnesium sulfate.
Choice D rationale: Administering an antihypertensive medication is important if the blood pressure remains elevated, but it is not specified as required before starting magnesium sulfate.
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