A nurse in an antepartum unit is caring for a client.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Lubricating the catheter with water-soluble gel is important but is done after preparing the sterile field.
B. Attaching a prefilled syringe to the catheter inflation hub is performed after insertion to secure the catheter, not before.
C. Cleansing the client’s meatus with antiseptic solution is essential for infection prevention but is done after the sterile field is set up.
D. Positioning the sterile drape while leaving the perineum exposed is the first step because it maintains a sterile field and provides a clean working area for catheter insertion. This prevents contamination and reduces the risk of infection.
Correct Answer is D
Explanation
A. A client who has heart failure and received furosemide IV 8 hr ago:
Clients with heart failure require ongoing monitoring for fluid balance, electrolyte levels, and signs of worsening symptoms. IV furosemide indicates active treatment, so this client is not stable for discharge.
B. A client who was admitted 24 hr ago with chest pain:
A client with recent chest pain requires further evaluation for acute coronary syndrome (ACS). Even if pain has resolved, monitoring for cardiac events is essential. This client is not stable for discharge.
C. A client who had a seizure 48 hr ago and is on seizure precautions:
Recent seizures require continued monitoring to assess for recurrence, medication adjustments, and safety precautions. This client is not stable for discharge.
D. A client who is scheduled to have a colonoscopy in 12 hr:
A colonoscopy is an elective procedure and does not require hospitalization. This client is stable and can be discharged to free up resources for mass casualty victims.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.