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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. Kegel exercises strengthen pelvic floor muscles but do not alleviate afterpains, which are uterine contractions occurring postpartum.
B. Applying a cool compress to the abdomen may provide some relief, but it is not as effective as pain medication in reducing the discomfort associated with afterpains.
C. Placing the client in a side-lying position may provide comfort but does not specifically address the pain from uterine contractions.
D. Administering ibuprofen is effective for pain relief due to its anti-inflammatory properties, which help reduce the discomfort associated with afterpains by alleviating the uterine contractions.
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