A nurse is assisting with providing care for a client who is in labor.
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
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"C"},"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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Group B Streptococcus (GBS) status is typically re-evaluated at around 36 weeks of gestation to determine if prophylactic antibiotics are needed during labor to prevent transmission to the baby.
B. A positive GBS test does not automatically indicate a cesarean birth. Intravenous antibiotics during labor are generally used to prevent transmission of GBS to the newborn.
C. GBS infection can cause serious complications in newborns, but hearing loss is not a typical outcome. The primary concerns are sepsis, pneumonia, and meningitis.
D. Antibiotics for GBS are given during labor, not the last two weeks of pregnancy. The treatment aims to reduce the risk of GBS transmission to the baby during delivery.
Correct Answer is A
Explanation
A. A single crease in the palm is correct. A single transverse palmar crease (simian line) is a common finding in infants with trisomy 21.
B. A notch in the lip is not a common finding in trisomy 21. This feature is more associated with other conditions like cleft lip or palate.
C. Extra digits on the hand (polydactyly) is not characteristic of trisomy 21. It is more commonly associated with other genetic conditions.
D. An inversion of the foot (clubfoot) is not a specific finding for trisomy 21. While some infants with trisomy 21 might have foot deformities, this is not a defining characteristic.
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