The nurse is called into a client's room by the unlicensed assistive personnel (UAP), who informs the nurse that the obstetric client has no pulse or respirations and has profuse vaginal bleeding. Which is the priority action by the nurse?
1. Apply gloves and assess the client for pulse and respirations.
2. Assess the client for pulse and respirations, instruct UAP to notify code team while donning personal protective equipment, and begin CPR.
3. Quickly assess pulse and respirations, next assess for bleeding, call for the code team, and then apply personal protective equipment before beginning CPR.
4. Apply gown, gloves, mask, and goggles, then assess client for pulse, respirations, and bleeding.
Correct Answer: 2
If the client is bleeding vaginally, it would be possible to assess carotid pulse and breathing without coming in contact with bloodborne pathogens. Once the nurse confirms that the client is pulseless, instruct the UAP to call a code while donning personal protective equipment and beginning CPR.
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