A nurse is assisting with the admission of a client to the labor and delivery unit.

Exhibits

Which of the following actions should the nurse recommend including in the client's plan of care? For each potential recommendation, click to specify if the recommendation is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Administer oxygen at 10 L/min via non-rebreather face mask as needed.

Position the client in lateral side-lying position.

Administer magnesium sulfate IV.

Encourage the client to void every 2 hr.

Administer prophylactic IV antibiotic.

Evaluate the client for uterine tachysystole.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Anticipated:

Administer oxygen at 10 L/min via non-rebreather face mask as needed: The client has late decelerations, indicating possible fetal hypoxia. Providing supplemental oxygen can enhance placental oxygenation and improve fetal status.
Position the client in lateral side-lying position: This position improves uteroplacental perfusion by relieving compression of the inferior vena cava, which can help resolve late decelerations and improve fetal oxygenation.
Encourage the client to void every 2 hr: A full bladder can impede fetal descent and contribute to labor discomfort. Regular voiding helps prevent bladder distention and promotes labor progress.
Administer prophylactic IV antibiotic: The client is positive for Group B streptococcus (GBS), which necessitates prophylactic antibiotic administration during labor to reduce the risk of neonatal infection.
Evaluate the client for uterine tachysystole: The client's contractions have increased in frequency and intensity. Assessing for excessive uterine activity is critical to prevent fetal distress and complications such as uterine rupture.

Contraindicated:

Administer magnesium sulfate IV: Magnesium sulfate is used for seizure prophylaxis in preeclampsia or for tocolysis in preterm labor. The client does not have preeclampsia, and labor is at term, making this intervention unnecessary.

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Correct Answer is B

Explanation

A. Completely undress the toddler. Toddlers may feel vulnerable when fully undressed. It is best to remove clothing gradually, assessing one area at a time, to promote comfort and reduce anxiety.
B. Allow the toddler to handle the equipment. Letting the toddler touch and explore medical equipment, such as a stethoscope or otoscope, helps reduce fear and increases cooperation during the examination. This approach fosters a sense of control and familiarity.
C. Thoroughly explain each procedure to the toddler. Toddlers have limited understanding and attention spans. Simple, short explanations and distraction techniques are more effective in easing anxiety than detailed explanations.
D. Start the examination with routine immunizations. Painful procedures, such as vaccinations, should be saved for the end of the visit to prevent distress and resistance that could interfere with the rest of the examination.

A. Increased intake of green, leafy vegetables B. Wears a face mask around others C. Uses a firm-bristled toothbrush D. Sleeps 8 to 10 hr per night

Correct Answer is C

Explanation

A. Increased intake of green, leafy vegetables does not inherently increase the risk for injury in clients with thrombocytopenia. In fact, these vegetables can provide essential vitamins and nutrients. However, clients may need to monitor their intake of vitamin K if they are on anticoagulant therapy, but this does not directly correlate with injury risk related to thrombocytopenia.
B. Wears a face mask around others is a precautionary measure typically used to prevent infection, especially in immunocompromised clients. This action does not increase the risk for injury; instead, it helps protect the client from potential pathogens.
C. Uses a firm-bristled toothbrush increases the risk for injury in clients with thrombocytopenia. A firm-bristled toothbrush can cause gum irritation and bleeding due to low platelet counts, which can lead to prolonged bleeding and increase the risk of oral injuries. Soft-bristled toothbrushes are recommended to minimize the risk of bleeding.
D. Sleeps 8 to 10 hr per night is a healthy behavior that supports overall well-being and recovery. Adequate sleep can help the body heal and does not increase the risk for injury in clients with thrombocytopenia.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify that which of the following findings increases the client's risk for injury?

Correct Answer is C

Explanation

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