A nurse is assisting with providing care for a client who is in labor.

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, click to specify if the intervention is anticipated, nonessential, or contraindicated for the client.

Encourage frequent ambulation.

Prepare the client for catheterization

Ensure the client maintains a supine position while in bed.

Check FHR every 30 min.

Perform a Nitrazine test.

Check client's temperature every hour.

Obtain CBC blood sample

Answer and Explanation

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

- Encourage frequent ambulation: Anticipated. Ambulation can help progress labor, unless contraindicated by the healthcare provider.

- Prepare the client for catheterization: Non-essential. There is no current indication for catheterization as the client is voiding adequately and not in active labor.

- Ensure the client maintains a supine position while in bed: Contraindicated. The supine position can cause supine hypotensive syndrome in pregnant clients. A side-lying position is preferred to optimize blood flow.

- Check FHR every 30 min: Anticipated. Regular monitoring of FHR is important to assess fetal well-being during labor.

- Perform a Nitrazine test: Anticipated. Since the client reports fluid leakage, a Nitrazine test can help confirm if the membranes have ruptured.

- Check client's temperature every hour: Non-essential. The client's temperature is stable, and hourly checks are not indicated unless there are signs of infection or the membrane has been ruptured for an extended period.

- Obtain CBC blood sample: Anticipated. A CBC can help identify any underlying issues such as anemia or infection that could affect labor and delivery.

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Correct Answer is B

Explanation

A. Insert the suppository 5 cm (2 in) is incorrect. The suppository should be inserted about 2-3 inches into the vaginal canal, not specifically 5 cm, but the exact depth may vary.
B. Insert the suppository along the posterior vaginal wall is correct. Inserting the suppository along the posterior vaginal wall helps ensure it reaches the area where it is needed for effective treatment.
C. Apply petroleum jelly to the suppository is incorrect. The suppository should not be coated with petroleum jelly; it should be used as is to avoid interference with its absorption and effectiveness.
D. Assist the client into a prone position is incorrect. The client should be assisted into a supine position with knees bent or into a lithotomy position for the insertion of the suppository, not a prone position.

Correct Answer is []

Explanation

- Potential Condition: Endometritis. The symptoms of malaise, chills, decreased appetite, elevated temperature, tachycardia, a boggy and tender uterus, and foul-smelling lochia are indicative of a postpartum infection, such as endometritis.

- Actions to Take:

- Monitor the lochia amount and odor: This will help assess the presence of infection and the effectiveness of treatment.

- Assist with the administration of prescribed antibiotics: Antibiotics are the primary treatment for endometritis.

- Parameters to Monitor:

- Temperature: Monitoring for fever can help assess the response to treatment and indicate if the infection is resolving or worsening.

- Heart rate: Tachycardia may be a sign of infection or other complications, so it's important to monitor changes in heart rate.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is []

Explanation

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