The nurse is caring for a gravida 5 in active labor. The membranes spontaneously rupture, with a large amount of clear amniotic fluid. Which nursing action is most important to undertake at this time?
1. Assess the odor of the amniotic fluid.
2. Perform Leopold's maneuvers.
3. Obtain an order for pain medication.
4. Complete a sterile vaginal exam.
4
Rationale 1: Although it is important to assess amniotic fluid for odors, checking the cervix to assess for cord prolapse is a higher priority.
Rationale 2: This assessment is not called for at this time.
Rationale 3: Pain medication is a low priority at this time.
Rationale 4: Checking the cervix will determine whether the cord prolapsed when the membranes ruptured. A prolapsed cord leads to rapid onset of fetal hypoxia, which can lead to fetal death within minutes if not treated.
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The nurse interviewing a patient with suspected posttraumatic stress disorder should be alert to findings indicating the patient: Select all that apply
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The nurse is caring for a patient who is taking a benzodiazepine. The nurse knows that caution should be used when administering a benzodiazepine to the elderly because of what possible adverse effect?
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