A woman laboring with a fetus in a breech position spontaneously ruptures her membranes. What action should the nurse take first?
a. Check the fetal heart rate.
b. Note the color of the amniotic fluid.
c. Check for a prolapsed cord.
d. Take maternal vital signs.
C
A prolapsing of the cord is a common breech presentation complication that can be facilitated by rupture of the membranes. While checking the fetal heart rate, noting the color of amniotic fluid and taking maternal vital signs are appropriate actions, in a breech presentation the priority is checking for the prolapsed cord.
You might also like to view...
A patient has been ordered a fentanyl patch known as Duragesic for chronic pain. What patient teaching should be provided to the patient and family?
A) Remove the patch every 3 days. B) Apply it to the chest only. C) Apply it for breakthrough pain. D) Remove it daily and clean skin.
The correct equation for converting 4 tbsp to milliliters is
A. x mL/1 tbsp.= 4 tbsp/15 tbsp B. 4 tbsp/x mL = 15 mL/1 tbsp. C. x mL/4 tbsp = 15 mL/1 tbsp. D. x mL/1 tbsp = 15 mL/4 tbsp.
What is the best plan as the nurse prepares to administer a topical medication?
1. Check the medication for interactions with other medications. 2. Take the patient's vital signs. 3. Educate the patient to not disturb the patch. 4. Assess the patient's skin where the medication will be applied.
The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician?
a. Weight gain of 2 pounds since last week b. Dry mucous membranes and skin tenting c. Urine output 8 mL/hr d. Blood pressure 98/58