The nurse is providing care to a client in labor who experiences ...

[cmoore54]

The nurse is providing care to a client in labor who experiences spontaneous rupture of membranes. The fetus is in the vertex position. The nurse notes that the amniotic fluid is meconium stained. Based on this data, which is the priority action by the nu
 
  A) Notifying the healthcare provider that birth is imminent
  B) Changing the client's position in bed
  C) Beginning continuous fetal heart rate monitoring
  D) Administering oxygen at 2 liters per minute

Question 2

What should the nurse do to assist a client brought to the emergency department as a victim of a gunshot wound?
 
  A) Ask the client who shot him.
  B) Bathe the client and provide a clean gown.
  C) Ask the client where the weapon is.
  D) Preserve the chain of evidence.

[briezy]

Answer to Question 1

Answer: C

Meconium-stained amniotic fluid is an abnormal fetal finding and is an indication for continuous fetal monitoring. Changing the client's position is not indicated. Meconium-stained amniotic fluid does not indicate that birth is imminent. Oxygen administration is not indicated.

Answer to Question 2

Answer: D

Because the majority of gunshot wounds require an investigation by law enforcement, nurses working in emergency departments and trauma centers should be familiar with their agency's protocols for maintaining evidence required by law enforcement. Often, law enforcement does not want the victim's hands or the area around the victim's wounds cleansed. Clothes and personal items are often wanted as evidence. The nurse should not bathe the client and provide a clean gown. The nurse should not ask the client who shot him or where the weapon is. The nurse should preserve the chain of evidence.

[cmoore54]

TYSM

[carlsona147]

Excellent