The nurse is caring for a client 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 maneuvers.
3. Obtain an order for pain medication.
4. Complete a sterile vaginal exam.
4
Explanation: 4. Checking the cervix will determine whether the cord prolapsed when the membranes ruptured. The nurse would assess for prolapsed cord via vaginal examination.
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A nurse is preparing to administer antiviral therapy. The nurse integrates knowledge of this therapy, administering the drugs cautiously to clients with which of the following? Select all that apply
A) Hepatic impairment B) Renal impairment C) Diabetes D) Low blood cell count E) Hypertension
Critical to caring for the immunocompromised patient is the understanding that:
a. the immunocompromised patient has normal white blood cell (WBC) physiology. b. the immunosuppression involves a single element or process. c. infection is the leading cause of death in these patients. d. immune incompetence is symptomatic even without pathogen exposure.
A client receiving magnesium sulfate IV at 1 gram an hour after a loading dose for preterm labor looks flushed and complains of feeling warm. What should the nurse's initial action be?
a. Perform a vaginal exam to determine progress. b. Reassure the client that this is a normal response. c. Stop the drug and call the physician. d. Turn the client on her left side and increase IV fluid.
A child is admitted with suspected appendicitis. The child is experiencing abdominal pain. Which intervention by the nurse is most appropriate?
a. Palpate for rebound tenderness b. Apply heat to abdomen c. Position child on side with knees drawn d. Encourage ambulation