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 C
Explanation
A. Catheterization may not be necessary at this time and can be uncomfortable for the client.
B. Using a bedpan may not be the most comfortable option for the client, who likely wants to ambulate.
C. Assisting the client to the bathroom is the best response to ensure her safety and prevent falls.
D. Dangling the legs over the side of the bed is not necessary in this situation and may not address the client's need to use the bathroom.
Correct Answer is D
Explanation
A. A FHR baseline of 125 is within the normal range for a fetal heart rate.
B. A temperature of 99.9°F is a mild elevation and may not be an immediate concern.
C. Blood pressure of 142/90 may be elevated but may not require immediate action unless associated with other concerning symptoms.
D. Contractions lasting 45-60 seconds are prolonged and may lead to decreased fetal oxygenation. This finding should be reported immediately to the charge nurse.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
