On admission to the labor and birth unit, a 38-year-old female, gravida 4, para 3, at term in early labor is found to have a transverse lie on vaginal examination. What is the priority intervention at this time?
a. Perform a vaginal exam to denote progress.
b. Notify the health care provider.
c. Initiate parenteral therapy.
d. Apply oxygen via nasal cannula at 8 L/min.
ANS: B
A transverse lie is considered to be an abnormal presentation so the physician should be notified and the process of a C section as the birth method should be initiated. The information provided relative to transverse lie was found on vaginal exam. At this point, the priority is to prepare for a surgical birth because assessment data also indicate that the client is in early labor; thus, a vaginal birth is not imminent. Although initiating parenteral therapy will be required, it is not the priority at this time. Application of oxygen is not required because there is no evidence of fetal or maternal distress.
You might also like to view...
A patient is admitted from the emergency department. The emergency department physician notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classification of IV. This indicates the patient's condition as:
a. moderate heart failure. b. severe heart failure. c. congestive heart failure. d. negligible heart failure.
While interviewing the spouse of a client who is being treated for substance abuse, the population health nurse suspects codependence exists between the client and the spouse. What characteristic of codependence did the nurse assess?
1. Evidence of high self-esteem. 2. The ability to freely express feelings. 3. Control of others. 4. The ability to stand up for one's own desires.
A client asks the nurse what he can do to prevent the onset of cancer. The nurse realizes that which of the following contribute to the development of cancer? (Select all that apply.)
1. Heredity 2. Environment 3. Lifestyle 4. Stress 5. Age 6. Blood pressure
MC The group of community activists is selecting its members, and identifying goals and purposes. These group tasks are congruent with which stages of the nursing process? (Select all that apply.)
A. Assessment B. Planning C. Diagnosis D. Evaluation E. Implementation