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. "Document the infiltration." While documentation is necessary, it is not the first action the nurse should take. Immediate intervention is required to prevent further complications from IV infiltration, such as tissue damage or fluid leakage into surrounding tissues.
B. "Stop the infusion." The first action the nurse should take is to stop the IV infusion to prevent further infiltration of fluid into the surrounding tissues. Continuing the infusion could worsen swelling, discomfort, and potential tissue injury.
C. "Elevate the arm." Elevating the affected extremity can help reduce swelling by promoting fluid reabsorption, but this should be done after stopping the infusion to prevent additional fluid from accumulating in the tissues.
D. "Apply a warm compress." A warm compress can help promote absorption of non-vesicant solutions, while a cold compress is preferred for certain medications to reduce swelling and pain. However, applying a compress should only be done after stopping the infusion and assessing the severity of infiltration.

A. Use aseptic technique during wound care for the client. B. Obtain the client's oxygen saturation levels. C. Check the client's WBC count. D. Regulate IV fluids to maintain the client's urinary output.

Correct Answer is B

Explanation

A. Use aseptic technique during wound care for the client. While using aseptic technique is essential for preventing infection during wound care, it is not the immediate priority upon admission. The nurse must first assess the client's airway and oxygenation status.
B. Obtain the client's oxygen saturation levels. Obtaining the client's oxygen saturation levels is the priority action. Clients with burns, especially those affecting the upper torso, may have compromised airway patency or inhalation injury. Assessing oxygen saturation is crucial for determining the need for supplemental oxygen or further airway interventions.
C. Check the client's WBC count. Checking the client's white blood cell (WBC) count is important for evaluating potential infection and overall health status, but it is not an immediate priority in the acute phase of burn management. The nurse should focus first on airway and respiratory assessment.
D. Regulate IV fluids to maintain the client's urinary output. Regulating IV fluids to maintain urinary output is an important action in managing burn clients, as fluid resuscitation is critical. However, it should be done after ensuring the client's airway and oxygenation are stable, as inadequate oxygenation could complicate fluid resuscitation efforts.

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Nursing Test Bank

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Explanation

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Explanation

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