The nurse is assisting a pregnant patient into bed after the patient reports a gush of fluid from the vagina. Which action will the nurse take first?
Place client on her left side
Notify RN immediately
Document the time and color of fluid
Check fetal heart tones
The Correct Answer is B
A. Placing the client on her left side is important for optimizing fetal oxygenation but is not the first action when there is a report of a gush of fluid.
B. Notifying the registered nurse (RN) immediately is the first action to ensure prompt assessment and appropriate interventions for possible ruptured membranes.
C. Documenting the time and color of the fluid is important, but immediate notification of the RN takes precedence.
D. Checking fetal heart tones is important but should be done in conjunction with notifying the RN to assess the overall situation and determine the appropriate course of action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Initiating oxytocin infusion is not the priority before the insertion of dinoprostone. Fetal monitoring is a more immediate concern.
B. Ensuring the client eats a light meal and drinks fluids is important for general well-being but is not the priority before dinoprostone insertion.
C. Placing the catheter and sterile saline at the bedside may be done later but is not the priority before insertion.
D. Continuous monitoring of the fetal heart rate and uterine activity is essential to assess the response to cervical ripening agents, as they can cause uterine hyperstimulation and fetal distress.
Correct Answer is A
Explanation
A. An epidural provides comprehensive pain relief by blocking sensation from the waist down, making it an effective option for clients experiencing intense pain during labor.
B. Effleurage (massage or light stroking) may provide some comfort but may not be sufficient for the described level of pain.
C. Opioids can provide pain relief but may not be as effective in managing the intense pain of contractions in active labor.
D. Sedatives may not be the best choice during active labor as they can have a sedating effect on both the mother and the baby, potentially affecting the progress of labor.
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