The nurse is caring for a client who is 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 take at this time?
1. Perform a Leopold maneuver.
2. Complete a sterile vaginal examination.
3. Obtain an order for pain medication.
4. Assess the odor of the amniotic fluid.
2
Explanation:
1. This assessment is not called for at this time.
2. 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.
3. Pain medication is a low priority at this time.
4. Although it is important to assess amniotic fluid for odors, checking the cervix to assess for cord prolapse is a higher priority.
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1. alter position every 2 hours 2. keep head of bed elevated 30 degrees 3. encourage deep breathing and coughing exercises 4. assist the patient during any physical activities
Nurses should be familiar with the concept of ethics and understand that it represents the concern for which of the following?
a. Others instead of oneself b. Oneself instead of others c. The general welfare of society as the proper goal of actions d. The welfare of the individual as opposed to groups as the proper goal of actions
Perineal care does which of the following?
a. Spreads infection b. Prevents cancer c. Promotes comfort d. Prevents burns