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":"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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
A. Douching is not recommended as it can disrupt the natural vaginal flora and potentially lead to further infections. Instead, maintaining good hygiene without douching is advised.
B. Urinating before bedtime is actually recommended to help flush out bacteria from the urinary tract. Avoiding urination at bedtime can increase the risk of developing a urinary tract infection.
C. Bubble baths can irritate the vaginal area and increase the risk of a urinary tract infection. Pregnant clients should be advised to avoid bubble baths and use mild, unscented soaps instead.
D. Yogurt products are beneficial because they contain probiotics that can help maintain a healthy balance of bacteria in the vagina and urinary tract. Eliminating yogurt from the diet is not necessary and may be counterproductive.
E. Wearing cotton-crotch underwear helps keep the vaginal area dry and reduces the risk of infections. Cotton allows for better air circulation and absorbs moisture compared to synthetic fabrics.
Correct Answer is B
Explanation
A. Decreased muscle tone is not a typical manifestation of neonatal abstinence syndrome. Symptoms of neonatal abstinence syndrome usually include increased muscle tone and irritability.
B. An exaggerated Moro reflex is a sign of neonatal abstinence syndrome. This reflex can be more pronounced in infants experiencing withdrawal from substances.
C. A weak cry is not characteristic of neonatal abstinence syndrome. Infants with this syndrome may have a high-pitched, excessive, or persistent cry.
D. Neonates with abstinence syndrome are difficult to console. They may have persistent crying and be hard to calm, which contrasts with the ability to console easily.
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.