A nurse is assisting with providing care for a 23-year-old female client who is in labor in the labor and delivery unit.

Exhibits

The nurse is assisting with planning care for the client. After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?

For each potential intervention, specify if the intervention is anticipated, nonessential, or contraindicated for the client.

Encourage frequent ambulation

Ensure the client maintains a supine position while in bed

Check FHR every 30 min

Perform a Nitrazine test

Prepare the client for catheterization

Obtain CBC blood sample

Check the client's temperature every hour

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"}}

Encourage frequent ambulation - Anticipated
- Ambulation can help progress labor and is generally encouraged if there are no contraindications.
Ensure the client maintains a supine position while in bed - Contraindicated
- Supine positioning can decrease uteroplacental blood flow and is generally not recommended during labor.
Check FHR every 30 min - Anticipated
- Regular monitoring of the fetal heart rate is essential to assess fetal well-being during labor.
Perform a Nitrazine test - Anticipated
- Since the client reports a gush of fluid, a Nitrazine test can help confirm whether the membranes have ruptured.
Prepare the client for catheterization - Nonessential
- The client has voided recently and doesn’t indicate difficulty, making catheterization unnecessary at this stage.
Obtain CBC blood sample - Anticipated
- A CBC can provide important information about the client's health status and identify any potential issues, like infection or anemia.
Check the client's temperature every hour - Anticipated
- Regularly monitoring temperature can help detect signs of infection, which is particularly important if the membranes have ruptured.

Intervention	Anticipated	Nonessential	Contraindicated
Encourage frequent ambulation	✔
Ensure the client maintains a supine position while in bed			✔
Check FHR every 30 min	✔
Perform a Nitrazine test	✔
Prepare the client for catheterization		✔
Obtain CBC blood sample	✔
Check the client's temperature every hour	✔

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

A client whose labor lasted for 6 hours is not necessarily a priority unless other complications are present. Duration of labor alone does not indicate an urgent need for immediate attention postpartum.

Choice B rationale

A client who received magnesium sulfate during labor should be seen first due to the potential for serious side effects such as respiratory depression, hypotonia in the newborn, and maternal complications. Magnesium sulfate is used to prevent seizures in clients with preeclampsia and requires close monitoring.

Choice C rationale

A client with a history of oligohydramnios needs monitoring, but this condition alone does not take precedence over the immediate postpartum risks associated with magnesium sulfate.

Choice D rationale

A client whose newborn is having difficulty latching-on needs support and assistance with breastfeeding. While important, this issue is not as urgent as monitoring the effects of magnesium sulfate in the client described in Choice B.

A. Take an over-the-counter antacid. B. Increase intake of fresh fruits. C. Eat dry, bland foods in the morning. D. Restrict fluids to 1,000 mL/day.

Correct Answer is C

Explanation

Choice A rationale

Taking an over-the-counter antacid is not recommended for managing nausea during pregnancy without consulting a healthcare provider. Some antacids contain ingredients that may not be safe during pregnancy.

Choice B rationale

Increasing intake of fresh fruits might help with hydration and nutrition but is not specifically effective in managing morning nausea. Some fruits might even exacerbate nausea due to their acidity.

Choice C rationale

Eating dry, bland foods in the morning can help manage nausea for pregnant clients. Foods like crackers, toast, and cereals are easy on the stomach and can help reduce morning sickness.

Choice D rationale

Restricting fluids to 1,000 mL/day is not advisable. Proper hydration is crucial during pregnancy, and such restriction can lead to dehydration and other complications. Fluids should be encouraged rather than restricted.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has just received change-of-shift report about four clients who are postpartum.Which of the following clients should the nurse plan to see first?

Correct Answer is B

Explanation

A nurse is caring for a client who is at 9 weeks of gestation and reports nausea in the morning that continues until midafternoon.Which of the following actions should the nurse encourage the client to take?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who is at 18 weeks of gestation and requires an increased intake of iron.Which of the following foods should the nurse recommend as the best source of iron?

A nurse is contributing to the plan of care for a client who is in early labor and reports low-back pain during contractions.Which of the following interventions should the nurse include in the plan?

A nurse is reinforcing teaching about perineal care to a client who is 2 hours postpartum and has an episiotomy and hemorrhoids.Which of the following statements by the client indicates understanding of the teaching?

A nurse is reinforcing teaching with a client who tested positive for group B streptococcus β-hemolytic (GBS) during a prior pregnancy and is at 30 weeks of gestation.Which of the following statements should the nurse make?

A nurse is assisting with a pelvic examination of a client during their first prenatal visit.Which of the following actions should the nurse take?

A nurse is assisting with the care of a client who has a prescription for magnesium sulfate.Which of the following adverse effects should the nurse report to the provider?

A nurse is assisting with the care of a postpartum female client who delivered vaginally 8 hours ago in the maternity unit. Exhibits Select the 3 findings that require immediate follow-up.