The nurse is caring for a laboring client who presents with ruptured membranes, frequent contractions, and bloody show. Which intervention should be performed first?
Establish IV access
Assess the client's vital signs
Obtain fetal heart rate
Perform a sterile vaginal exam
The Correct Answer is C
A. Establish IV access: Although important for hydration and medication administration, it is not the immediate priority when assessing the fetal condition.
B. Assess the client's vital signs: While important, the immediate assessment of fetal well-being takes precedence to ensure there is no fetal distress.
C. Obtain fetal heart rate: This is crucial to assess the fetus’s condition immediately. Monitoring the fetal heart rate can identify any signs of distress and determine if urgent interventions are necessary.
D. Perform a sterile vaginal exam: This should follow the fetal heart rate assessment to check for labor progress and any complications, but it is not the first priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Once I am fitted for the diaphragm it will always be the correct size. Incorrect because weight changes, pregnancy, or pelvic surgery may require refitting.
B. I need to leave the diaphragm in for six hours after the last act of intercourse. This is correct to ensure that all sperm are inactivated.
C. This contraceptive can be used during menstruation. Incorrect because it's generally not recommended to use the diaphragm during menstruation due to increased risk of infection.
D. I can leave the diaphragm in for a day or two. Incorrect because leaving it in for more than 24 hours can increase the risk of infection, including toxic shock syndrome.
Correct Answer is C
Explanation
A. Establish IV access: Although important for hydration and medication administration, it is not the immediate priority when assessing the fetal condition.
B. Assess the client's vital signs: While important, the immediate assessment of fetal well-being takes precedence to ensure there is no fetal distress.
C. Obtain fetal heart rate: This is crucial to assess the fetus’s condition immediately. Monitoring the fetal heart rate can identify any signs of distress and determine if urgent interventions are necessary.
D. Perform a sterile vaginal exam: This should follow the fetal heart rate assessment to check for labor progress and any complications, but it is not the first priority.
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