A nurse is admitting a female client, age 34, who is at 38 weeks of gestation to the labor and delivery unit for induction of labor.
Which of the following actions should the nurse take prior to implementing the provider’s prescriptions?
Ensure calcium gluconate is readily available.
Obtain the client’s heart rate.
Evaluate the client’s platelet count.
Determine if the client has aspirin sensitivity.
Review the client’s history for documentation of heart disease.
Correct Answer : A,B,D,E
Choice A rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity, often used in labor inductions complicated by preeclampsia or gestational hypertension. Having it readily available ensures prompt treatment of symptoms like respiratory depression or cardiac arrhythmias caused by magnesium overdose. This safety measure is critical because oxytocin use can increase uterine contractions and magnesium sulfate use requires close monitoring to prevent toxicity.
Choice B rationale: Obtaining the client’s heart rate prior to initiating oxytocin is essential to establish a baseline and monitor for tachycardia or bradycardia, which may affect maternal and fetal safety. Oxytocin can cause cardiovascular changes, including hypertension or arrhythmias, especially in clients with gestational hypertension. Continuous maternal cardiac assessment helps detect adverse effects early and adjust treatment accordingly.
Choice C rationale: Evaluating platelet count before induction is important in clients with gestational hypertension due to the risk of HELLP syndrome, which involves thrombocytopenia. Normal platelet levels range from 150,000 to 400,000/mm³; low levels increase bleeding risk during labor and delivery. Knowing platelet status guides safe management decisions, including anesthesia options and readiness for potential hemorrhagic complications.
Choice D rationale: Assessing for aspirin sensitivity is crucial because aspirin is often used in pregnancy for preeclampsia prevention. Aspirin hypersensitivity can lead to allergic reactions or exacerbation of asthma. Since the client has gestational hypertension, determining aspirin tolerance before administering medications is necessary to prevent adverse drug reactions and ensure safe pharmacologic management.
Choice E rationale: Reviewing the client’s history for heart disease documentation is vital as gestational hypertension increases cardiovascular risk. Preexisting heart conditions can complicate labor induction and oxytocin administration due to possible cardiac overload or arrhythmias. A comprehensive cardiac history ensures appropriate monitoring and interventions to prevent maternal and fetal complications during labor.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Herpes simplex virus 2 (HSV-2) can be harmful to a developing fetus and newborn. While primary infection during the first trimester can rarely lead to congenital anomalies, the most significant risk is neonatal herpes, which occurs when the newborn is exposed to the virus during passage through the birth canal if active lesions are present. Neonatal herpes can cause severe, life-threatening complications.
Choice B rationale
Transmission of HSV-2 to the newborn is significantly higher if active genital lesions are present at the time of vaginal birth. The virus can be shed from these lesions and infect the infant as they pass through the birth canal. Therefore, a Cesarean section is typically recommended if active lesions are present at the onset of labor.
Choice C rationale
Wearing tight-fitting undergarments can increase moisture and friction, potentially irritating existing lesions and hindering healing. Loose-fitting cotton undergarments are generally recommended to allow air circulation and reduce irritation, promoting a more favorable environment for lesion resolution and comfort.
Choice D rationale
Antiviral medications, such as acyclovir, valacyclovir, or famciclovir, can help manage genital herpes by reducing the frequency, duration, and severity of outbreaks. They work by inhibiting viral replication. However, these medications do not cure the condition; HSV-2 remains a lifelong viral infection.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
- Discontinue oxytocin infusion (Expected): The client has contractions every 1–2 minutes lasting 90–120 seconds, indicating uterine tachysystole. Stopping oxytocin is a primary intervention to reduce contraction frequency and duration, preventing further fetal hypoxia.
- Assist with amnioinfusion (Expected): Amnioinfusion can help dilute thick meconium-stained amniotic fluid or relieve cord compression, which can cause late decelerations and minimal variability in FHR. It is often used to improve fetal oxygenation during uterine hyperstimulation.
- Give 500 mL of lactated Ringer’s IV bolus (Expected): Increasing maternal hydration improves uteroplacental perfusion, which can be compromised during frequent contractions. This intervention helps restore blood volume and oxygen delivery to the fetus.
- Place the client in a side-lying position (Expected): Lateral positioning improves uterine blood flow by relieving pressure on the vena cava and optimizing cardiac output and fetal oxygenation.
- Give betamethasone 12 mg IM now (Unexpected): Betamethasone is administered antenatally to accelerate fetal lung maturity in preterm labor (before 34 weeks). This client is at 38 weeks gestation, so corticosteroids are not indicated.
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