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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Fever is not a common adverse effect of epidural anesthesia. Fever is more commonly associated with infection or other causes and would require further investigation but is not directly linked to the epidural itself.
B. Tachypnea is not an expected adverse effect of epidural anesthesia. It may be a sign of anxiety, pain, or respiratory complications, but it is not typically caused by the epidural.
C. Tachycardia can be an adverse effect of epidural anesthesia. It may occur as a compensatory mechanism due to hypotension, which is a known side effect of epidural anesthesia. When blood pressure drops, the heart rate may increase to maintain cardiac output.
D. Hypertension is generally not associated with epidural anesthesia. Hypotension is more common due to the vasodilatory effects caused by sympathetic nerve blockade, rather than an increase in blood pressure.
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.
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