Level: Foundational
Difficulty: Easy
Subtopic: Fetal monitoring
NCLEX: A 29-year-old client in labor and delivery is being evaluated for labor with external fetal monitoring. Assessmen…
Maternal-newborn nursing Clinical Judgment Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A 29-year-old client in labor and delivery is being evaluated for labor with external fetal monitoring. Assessment data include contractions every 1 minute with no resting tone between contractions. Using the clinical judgment model, what is the nurse's first step?
Question
A. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
B. Implement the first intervention on the existing care plan without reviewing new data.
C. Evaluate discharge readiness before addressing acute findings.
D. Document the assessment at the end of the shift and continue the prior plan.
B. Implement the first intervention on the existing care plan without reviewing new data.
C. Evaluate discharge readiness before addressing acute findings.
D. Document the assessment at the end of the shift and continue the prior plan.
Rationale
Correct answer: A. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.