At the peak of a contraction, meconium-stained fluid gushes from a client's vagina. The nurse should immediately
a. call the physician c. check the fetal heart rate
b. change the bedding d. position the client on her right side
C
Meconium-stained amniotic fluid is an indication of fetal distress, so the fetal heart tones should be assessed by the nurse immediately. While the health care provider should be notified and bed linens would be changed, these actions are not the first actions the nurse should take. Maternal position should be changed to the left lateral position.
You might also like to view...
The nurse is performing a focused interview with a client who has been cleaning the ears with a cotton-tipped applicator. Which complications of this practice will the nurse include in the teaching session for this client?
Select all that apply. 1. Increasing risk of developing otitis externa. 2. Developing tophi along the outer rim of the ears. 3. Perforating the tympanic membrane. 4. Needing tympanostomy tubes. 5. Impacting cerumen.
When the head of the patient's bed is at a 90° angle, the JVP reading would be
a. absent. c. excelerated. b. bounding. d. greater than 4 cm.
The nurse is caring for a patient who has returned to the postsurgical suite after post-anesthetic recovery from a nephrectomy
The nurse's most recent hourly assessment reveals a significant drop in level of consciousness and BP as well as scant urine output over the past hour. What is the nurse's best response? A) Assess the patient for signs of bleeding and inform the physician. B) Monitor the patient's vital signs every 15 minutes for the next hour. C) Reposition the patient and reassess vital signs. D) Palpate the patient's flanks for pain and inform the physician.
The nurse is preparing a presentation highlighting the benefits of annual influenza vaccination. The nurse correctly targets which groups? (Select all that apply.)
a. The parents of children 3 to 6 months of age b. Diabetics who are over 50 years old c. Pregnant women d. Home health aides e. CNAs who work in long-term care facili-ties