The practical nurse (PN) is assigned to assist in the care of a client at 34-weeks gestation with premature rupture of membranes (PROM). Four hours after admission, the PN recognizes an increasing trend in the maternal heart rate. Which action should the PN take?
Follow contact precautions when providing care.
Insert a urinary catheter to monitor hourly output.
Encourage the client to push with the next contraction.
Initiate oxygen via face mask at 8 to 10 L/min.
The Correct Answer is D
An increasing trend in maternal heart rate is a sign of fetal distress, which can be a serious complication of PROM. One of the primary interventions for fetal distress is to increase oxygen delivery to the fetus. The practical nurse should initiate oxygen via face mask at 8 to 10 L/min to improve fetal oxygenation.
Contact precautions may be necessary for certain conditions, but they are not indicated for an increasing maternal heart rate.
Inserting a urinary catheter may be appropriate for monitoring output, but it is not the first priority in this situation.
Encouraging the client to push is not appropriate because the client is not in active labor and pushing can cause further complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The most important action for the PN to implement is to **assess the vital signs**. Saturation of a peripad within 15 minutes to 1 hour after delivery must be promptly reported. Data such as the amount of bleeding, the condition of the uterus, checking the maternal vital signs, and observing for signs of shock would play a vital role in the care of the patient with hemorrhage¹. Early recognition and treatment of PPH are critical to care management.
Correct Answer is B
Explanation
Placenta previa is a condition in which the placenta partially or completely covers the cervix, which can lead to vaginal bleeding during pregnancy. In severe cases, this bleeding can be life-threatening and can lead to hemorrhage. Therefore, the PN should closely monitor the client for any signs of bleeding or hemorrhage, such as excessive vaginal bleeding, hypotension, tachycardia, or signs of shock. The PN should also ensure that the client receives appropriate medical interventions and that emergency measures are in place in case of sudden bleeding or hemorrhage.
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