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 B
Explanation
The best indicator to the practical nurse (PN) that the community bicycle safety education program was effective is that the number of students wearing bicycle helmets increased by 10%. Wearing a helmet while riding a bicycle is an important safety measure that can help prevent head injuries in the event of an accident. An increase in the number of students wearing helmets indicates that the program was successful in promoting this safety behavior. The other findings listed may also provide useful information about the effectiveness of the program, but the increase in helmet use is the most direct and measurable indicator of success.
Correct Answer is D
Explanation
Encouraging the client to initiate daily rituals, such as practicing relaxation techniques, engaging in physical exercise, and spending time with friends and family, can be an effective way to diminish anxiety. These activities can provide a sense of structure and routine that can help to manage stress and anxiety. Options A and C are not recommended because alcohol and caffeine can worsen sleeplessness and anxiety. Option B can be counterproductive and increase the client's anxiety level. Therefore, Option D is the best option to assist this client in diminishing his anxiety.
Therefore, options A, B, and C are not answers because they are not the best action to assist this client in diminishing his anxiety.
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