The laboring patient presses the call light and reports that her water has just broken. The nurse's first action would be to:
1. Check fetal heart tones.
2. Encourage the mother to go for a walk.
3. Change bed linens.
4. Call the physician.
1
Rationale 1: Fetal heart tones should be checked after rupture of the membranes to assess for cord compression.
Rationale 2: If the presenting part is not engaged, the laboring patient should not be allowed to walk, because there is a risk of cord prolapse once the membranes have ruptured.
Rationale 3: The bed linens can be changed after assessing the heart rate.
Rationale 4: The physician does not need to be called after rupture of the membranes unless there is a change in the status of the fetus or patient.
You might also like to view...
Which of the following best describes the challenges when providing care to someone from a minority group? (Select all that apply.)
a. Communication, both words and gestures, may be unfamiliar. b. Few members of the minority group are nurses themselves. c. Immigrants will soon adapt to the mainstream culture, but in the meantime many are clinging to "the old ways." d. So few patients are minority group members that it is difficult to remember how they prefer to receive care. e. The nurse may have to confront personal values and beliefs.
A client is prescribed IV phenytoin 300 mg. The nurse will administer this IV bolus over:
a. 3 minutes. c. 15 minutes. b. 6 minutes. d. 30 minutes.
What is the primary concern for a nurse when considering ethical decision making?
A) The rights of the client involved B) The maintaining of professional values C) The affect the decision will have on the profession of nursing D) The preservation of one's personal values
When educating a new mother on infant care, it is important to inform her that maternal anxiety will cause a child to be
A) Outgoing B) Anxious C) Content D) Shy