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 C
Explanation
A. Blood pressure 156/80 mm Hg is incorrect. While this blood pressure reading is elevated, hypertension is not a typical immediate sign of postpartum hemorrhage. Hemorrhage is more commonly associated with hypotension (low blood pressure) due to fluid loss.
B. Temperature 38.3° C (101° F) is incorrect. A mild fever may be common in the first 24 hours postpartum due to normal inflammatory responses. It is not specifically indicative of postpartum hemorrhage, though a persistent fever could indicate an infection.
C. Respiratory rate 32/min is correct. An increased respiratory rate can be a sign of hypovolemia (due to significant blood loss), which may occur with postpartum hemorrhage. The body compensates for decreased blood volume by increasing the respiratory rate.
D. Apical pulse 66/min is incorrect. A heart rate of 66/min is within normal limits and would not be indicative of postpartum hemorrhage. In fact, a tachycardic (elevated) heart rate is more concerning in the case of hemorrhage as the body tries to compensate for blood loss.
Correct Answer is D
Explanation
A. Terbutaline is typically used to manage preterm labor, not a contraindication for dinoprostone, which is used for labor induction.
B. FHR (Fetal Heart Rate) of 140/min with moderate variability is within normal limits and would not be a reason to withhold dinoprostone.
C. WBC count is within normal limits, indicating no infection, thus not a contraindication for dinoprostone.
D. Lesions noted on vaginal introitus and labia majora could indicate an active Herpes simplex virus infection, which is a contraindication for vaginal delivery due to the risk of neonatal infection.
E. Breech presentation is a concern for delivery method but does not contraindicate the use of dinoprostone for labor induction.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.