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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["6"]

Explanation

Step 1 is: Determine the oxytocin concentration in milliunits per mL:. 20,000 milliunits ÷ 1,000 mL = 20 milliunits/mL.

Step 2 is: Calculate the flow rate in mL/hour:. 2 milliunits/min ÷ 20 milliunits/mL × 60 min/hour = 6 mL/hour.

Final answer: 6.

A. Bathe the newborn in warm water and swaddle in 2 blankets. B. Place the newborn on the radiant warmer. C. Maintain a room temperature above 70° F (21.1° C). D. Dry off the newborn and place skin-to-skin.

Correct Answer is D

Explanation

Choice A rationale

Bathing the newborn in warm water and swaddling in 2 blankets is not the best immediate action to prevent cold stress. While keeping the newborn warm is crucial, bathing immediately after birth can lead to rapid heat loss, and swaddling alone may not provide sufficient warmth.

Choice B rationale

Placing the newborn on a radiant warmer is an effective method to prevent cold stress, but it is not as beneficial as skin-to-skin contact, which provides both warmth and bonding. Radiant warmers are used primarily in situations where the infant requires stabilization or when skin-to-skin is not feasible.

Choice C rationale

Maintaining a room temperature above 70° F (21.1° C) helps to create a warmer environment, but it does not address the immediate need to prevent heat loss in the newborn. Room temperature alone may not be adequate to prevent cold stress, especially in preterm or low birth weight infants.

Choice D rationale

Drying off the newborn and placing them skin-to-skin with the mother is highly effective in preventing cold stress. This technique promotes thermal regulation through direct skin contact, which transfers body heat from the mother to the infant, stabilizes body temperature, and supports bonding and breastfeeding.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is scheduled for induction of labor receives a prescription for oxytocin 2 milliunits/min intravenously (IV). The IV bag contains oxytocin 20 units in lactated Ringer's 1 liter. How many mL/hour should the nurse program the infusion pump to deliver? (Enter numerical value only)

Correct Answer is ["6"]

Explanation

The nurse is caring for a term infant immediately following delivery.Which action should the nurse implement to reduce the risk of cold stress?

Correct Answer is D

Explanation

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4°F (38°C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

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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.

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