A nurse is admitting a client who experienced a vaginal birth 2 hours ago. The client is receiving an IV of lactated Ringer's with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification?

Methylergonovine 0.2 mg IM now.

Insert an indwelling urinary catheter.

Obtain laboratory study of prothrombin and partial thromboplastin time.

Administer oxygen by nonrebreather mask at 5 L/min.

Answer and Explanation

The Correct Answer is A

Choice a reason:
Methylergonovine is a medication used to prevent or control postpartum hemorrhage by contracting the uterus. However, it is contraindicated in patients with hypertension, as it can further increase blood pressure. Given that the client's blood pressure is already elevated at 146/94 mm Hg, administering methylergonovine could pose a risk. Therefore, this prescription requires clarification from the provider before administration.

Choice b reason:
Inserting an indwelling urinary catheter can be a standard procedure after vaginal birth if the client is unable to void or if accurate measurement of urine output is needed. This does not require clarification unless there are specific contraindications or the client's condition does not warrant it.

Choice c reason:
Obtaining a laboratory study of prothrombin and partial thromboplastin time is a common practice to assess the blood's clotting ability, especially if there is a concern for bleeding disorders or if the client is at risk for postpartum hemorrhage. This prescription is clear and does not require further clarification.

Choice d reason:
Administering oxygen by nonrebreather mask at 5 L/min may be indicated if the client is showing signs of respiratory distress or hypoxia. The client's current respiratory rate is within normal limits, but if there are concerns about oxygenation, this intervention would be appropriate.

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Correct Answer is A

Explanation

Choice A reason:
Encouraging the client to empty her bladder every 2 hours is important because a full bladder can impede the progress of labor and increase the risk of bladder distension, which can lead to postpartum urinary retention or bladder atony. Additionally, a full bladder can obstruct the descent of the fetus and may contribute to labor dystocia. The normal range for urination frequency is typically every 3 to 4 hours, but during labor, more frequent emptying is beneficial.

Choice B reason:
While it may seem intuitive to remind the client to bear down with each contraction to aid in the delivery process, this is not recommended during the active phase of the first stage of labor. Bearing down, or pushing, is generally reserved for the second stage of labor when the cervix is fully dilated. Premature bearing down can lead to maternal exhaustion and increase the risk of cervical edema or lacerations.

Choice C reason:
Maintaining the client in the lithotomy position is not necessary during the active phase of the first stage of labor. This position is typically used during the delivery process in the second stage of labor. During the active phase, the client should be encouraged to find a comfortable position that facilitates labor progress, such as walking, squatting, or using a birthing ball.

Choice D reason:
Performing vaginal examinations frequently is not advised because it can increase the risk of introducing infections and can be uncomfortable for the client. Vaginal examinations should be performed judiciously to assess labor progress, typically not more than every 4 hours unless there is a specific indication to do so.

A. Immediately report the situation to the client's provider and prepare the client for induction of labor. B. Turn the client onto her left side. C. Encourage the client to walk around without the monitoring unit for 10 minutes, then resume monitoring. D. Offer the client a snack of orange juice and crackers.

Correct Answer is D

Explanation

Choice A reason:
Reporting the situation to the provider and preparing for induction of labor may be premature without first attempting to stimulate fetal movement. Nonstress tests can have periods of no observed movement without indicating immediate distress or the need for labor induction.

Choice B reason:
Turning the client onto her left side can improve uteroplacental blood flow, which might indirectly stimulate fetal movement. However, this action alone may not be sufficient to prompt fetal activity during a nonstress test.

Choice C reason:
Encouraging the client to walk around could potentially stimulate fetal movement, but it is not the standard initial response during a nonstress test. Walking without monitoring may also miss capturing any potential movements that occur during that time.

Choice D reason:
Offering the client a snack of orange juice and crackers is a common and non-invasive method to encourage fetal movement. The natural sugars in the orange juice can increase the baby's blood glucose levels, potentially leading to increased activity that can be observed on the nonstress test.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

Correct Answer is A

Explanation

A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 minutes. Which of the following actions should the nurse perform?

Correct Answer is D

Explanation

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 minutes. The nurse suspects placenta previa. Which of the following is an appropriate nursing action?

A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make?

A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis?

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive?

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?