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.
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Related Questions
Correct Answer is D
Explanation
A. Encourage the client to empty her bladder. This might help if the fundus were not midline, but since it is firm and midline, it’s not necessary.
B. Notify the client's provider. Immediate notification is not required for these findings as they are within the expected range postpartum.
C. Increase the frequency of fundal massage. Frequent fundal massage is not necessary since the fundus is already firm.
D. Document the findings and continue to monitor the client. A firm fundus with moderate bleeding and small clots can be normal in the immediate postpartum period. The nurse should document these findings and continue to monitor.
Correct Answer is ["A","B","E","F"]
Explanation
A. Substance use. Parents or caregivers who use substances are more likely to abuse children due to impaired judgment and increased stress levels.
B. Extreme stress. High levels of stress in the family can increase the risk of child abuse as it can lead to frustration and inappropriate coping mechanisms.
C. High socioeconomic background. This is not typically associated with increased risk of child abuse; abuse can occur across all socioeconomic levels, but certain stressors are more prevalent in lower socioeconomic contexts.
D. Strong support system. A strong support system typically acts as a protective factor against child abuse by providing resources and emotional support to caregivers.
E. Prematurity. Premature infants often have increased care needs, which can lead to parental stress and potential abuse.
F. Chronic illness. Children with chronic illnesses may require more care, leading to caregiver stress and higher risk of abuse.
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