The nurse is caring for a gravida 5 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's maneuver.
3. Obtain an order for pain medication.
4. Complete a sterile vaginal exam.
4
Rationale:
1. Although it is important to assess amniotic fluid for odors, checking the cervix to assess for cord prolapse is a higher priority.
2. This assessment is not called for at this time.
3. Pain medication is a low priority at this time.
4. Checking the cervix will determine whether the cord prolapsed when the membranes ruptured. A prolapsed cord leads to rapid onset of fetal hypoxia, which can lead to fetal death within minutes if not treated.
You might also like to view...
The nurse providing information about the hepatitis B vaccine would include the information that the inoculation
a. consists of a single injection but is extremely uncomfortable. b. is given by three separate injections over 6 months. c. is recommended only for adults and those at risk. d. works best when it is given in the gluteal muscle.
A client recently diagnosed with type 1 diabetes mellitus asks the nurse to explain, "What's wrong with my pancreas?" The nurse's response is based on the knowledge that there is a malfunction of pancreas:
1. Beta cells. 2. Alpha cells. 3. Delta cells. 4. PP cells.
A client is diagnosed with a parasitic infection. The nurse realizes that which of the following white blood cell counts will be elevated?
1. Basophils 2. Eosinophils 3. Lymphocytes 4. Neutrophils
The nurse who compares the rate of teenage pregnancy in various areas of the city is practic-ing the public health core function of:
1. Assurance 2. Assessment 3. Prevention 4. Policy development