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.

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.

A. Administer aspirin for pain. Aspirin is an antiplatelet medication and is not appropriate for managing pain in a client with deep vein thrombosis (DVT). Additionally, aspirin can increase the risk of bleeding, especially in clients receiving anticoagulant therapy, so it should be avoided in this context.
B. Apply an ice pack to the affected extremity for 20 min every 2 hr. While ice packs may be helpful in reducing swelling, applying ice is generally not recommended for DVT because it may cause vasoconstriction and increase the risk of thrombosis. It’s more important to follow appropriate medical treatment guidelines for DVT management.
C. Massage the affected extremity every 4 hr. Massaging the affected extremity is contraindicated in cases of DVT, as it can dislodge the thrombus, potentially leading to a pulmonary embolism or other serious complications.
D. Initiate bed rest. Initiating bed rest is the appropriate action for a client with DVT. Bed rest helps prevent further clot formation and reduces the risk of complications. The healthcare provider will also typically order anticoagulant therapy to manage the condition safely. The client should avoid movement of the affected leg until medically advised otherwise.