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A nurse in an antepartum unit is caring for a client.

Exhibits
Which of the following actions should the nurse take? Select all that apply.

Administer oxygen at 10L/min via nonrebreather face mask.

Request a prescription for hydralazine.

Initiate a bolus of IV fluid.

Assist the client to the left lateral position.

Request a prescription for oxytocin.

Notify the provider of the client's condition.

Prepare to administer an amnioinfusion.

Answer and Explanation

Correct Answer : A,C,D,F,G

A. Administer oxygen at 10 L/min via nonrebreather face mask. The fetal heart rate (FHR) is 168/min with minimal variability, which indicates potential fetal distress or hypoxia. Providing oxygen can improve fetal oxygenation.

B. Request a prescription for hydralazine. Hydralazine is used for severe hypertension in pregnancy (BP ≥160/110 mm Hg). The client’s BP is 132/84 mm Hg, which does not indicate a need for antihypertensive medication at this time.

C. Initiate a bolus of IV fluid. IV fluid bolus can improve placental perfusion, increase maternal blood pressure (if hypotension is a concern), and correct fetal heart rate abnormalities. This is especially important with minimal variability.

D. Assist the client to the left lateral position. Repositioning to the left lateral position improves uteroplacental blood flow and may help correct FHR abnormalities.

E. Request a prescription for oxytocin. Oxytocin is used to augment labor. However, the priority here is managing fetal distress, not increasing contractions. Oxytocin may worsen fetal distress, so it is not appropriate at this time.

F. Notify the provider of the client's condition. The combination of tachycardia (FHR 168/min), minimal variability, and meconium-stained fluid indicates possible fetal distress. The provider must be notified immediately to determine further interventions.

G. Prepare to administer an amnioinfusion. Meconium-stained fluid increases the risk of meconium aspiration syndrome. An amnioinfusion (infusion of sterile fluid into the amniotic sac via an intrauterine catheter) can help dilute thick meconium and improve fetal well-being.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Breathlessness is not a typical symptom of a sliding hiatal hernia. However, in severe cases, large hernias may cause shortness of breath due to pressure on the diaphragm.
B. Heartburn (acid reflux) is a common symptom because the hernia allows stomach acid to move up into the esophagus, causing irritation and discomfort.
C. Abdominal cramping is not a primary symptom of a sliding hiatal hernia. Cramping is more commonly associated with gastrointestinal conditions like irritable bowel syndrome (IBS) or gastroenteritis.
D. Constipation is not directly linked to a sliding hiatal hernia. Instead, symptoms usually involve gastroesophageal reflux disease (GERD)-related issues, such as heartburn and regurgitation.

A. The client has been in the restraints for 4 hr. B. The client can explain the reasons for their behavior. C. The client is able to calmly follow commands." D. The client reports that the restraints are too tight.

Correct Answer is C

Explanation

A. The client has been in the restraints for 4 hr. This is incorrect because the duration of restraint use is determined by the client's behavior and safety, not a set time frame. Restraints should be discontinued as soon as they are no longer necessary.
B. The client can explain the reasons for their behavior. This is incorrect because insight into behavior does not necessarily indicate that the client is no longer a danger to themselves or others.
C. The client is able to calmly follow commands. This is correct because the primary indication for removing restraints is when the client demonstrates self-control and the ability to follow directions, reducing the risk of harm.
D. The client reports that the restraints are too tight. This is incorrect because a complaint of tight restraints indicates a need for reassessment and possible adjustment, but not necessarily discontinuation.

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A nurse in an antepartum unit is caring for a client. Exhibits Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

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A nurse is assessing a client who has a sliding hiatal hernia. Which of the following findings should the nurse expect?

Correct Answer is B

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A nurse in an antepartum unit is caring for a client.

Exhibits
Which of the following actions should the nurse take? Select all that apply.