A client in labor states, 'I think my water just broke!' The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first?

Correct Answer: C

Rationale: The correct answer is C: Place the client in Trendelenburg. This position helps alleviate pressure on the umbilical cord, preventing compression and improving blood flow to the fetus. It is crucial to prioritize this action to prevent fetal distress or compromise. Administering oxygen (A) is important, but not the initial priority. Notifying the operating room team (B) may be necessary but is not the immediate action. Administering a fluid bolus (D) is not indicated in this situation. Placing the client in Trendelenburg is the most appropriate and urgent action to ensure the safety and well-being of the fetus.

Correct Answer: D

Rationale: The correct answer is D: Do not expose other children. RSV is very contagious even without direct oral contact. Rationale: RSV is highly contagious and can spread through respiratory droplets, making it important to prevent exposing other children to the virus. Even without direct oral contact, the virus can be transmitted. Therefore, it is crucial to avoid putting other children at risk of contracting RSV. Summary of other choices: A: Wearing a mask may not be practical for an infant and may not provide sufficient protection against RSV transmission. B: RSV can still be contagious for several days after symptoms appear, so the child may still be able to spread the virus. C: While avoiding infants under 6 months can be a good precaution, all children should be protected from exposure to RSV due to its high contagiousness.

Correct Answer: A

Rationale: The correct answer is A: Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q8 hours. In a patient with urinary sepsis, timely administration of antibiotics is crucial to prevent further complications. Piperacillin/tazobactam is a broad-spectrum antibiotic effective against a wide range of bacteria commonly involved in sepsis. Administering it first ensures prompt initiation of treatment. Other choices (B) Vancomycin, (C) Pantoprazole, and (D) Enoxaparin are important medications but are not as time-sensitive in this scenario. Vancomycin and Enoxaparin have longer administration times, and Pantoprazole is a maintenance medication that is not urgent in the acute management of sepsis.

Correct Answer: D

Rationale: The correct answer is D: Monitor the client's intravenous site hourly during the treatment. This is crucial to reduce the risk of vesicant extravasation, which can cause tissue damage if the chemotherapy leaks into the surrounding tissues. By monitoring the IV site hourly, the healthcare provider can detect any signs of infiltration or extravasation early and take necessary actions to prevent further harm. A: Administering an antiemetic before starting chemotherapy is unrelated to preventing vesicant extravasation. B: Instructing the client to drink plenty of fluids does not directly address the risk of vesicant extravasation. C: Keeping the head of the bed elevated is not specific to preventing vesicant extravasation and may not effectively reduce the risk.

Correct Answer: B

Rationale: The correct answer is B: Encourage the client to schedule a digital rectal exam. This option is correct because the client's symptoms of nocturia, weak urine flow, and difficulty initiating urine stream suggest potential prostate issues, such as benign prostatic hyperplasia (BPH). A digital rectal exam can help assess the size and condition of the prostate gland. It is an essential step in diagnosing BPH or other prostate conditions. Other choices are incorrect because: A: Obtaining a urine specimen for culture and sensitivity is not the priority in this case, as the client's symptoms are more indicative of a prostate issue rather than a urinary tract infection. C: Maintaining a voiding diary may provide information on the frequency and volume of urine output, but it does not address the underlying cause of the client's symptoms. D: Instructing the client in cleansing techniques for the glans penis is not relevant to the reported symptoms and does not address the potential prostate issue.