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.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Inject 15 units of air into the regular insulin vial. When mixing NPH and regular insulin, air is first injected into both vials without touching the solution. After injecting air into the NPH vial, the next step is to inject air into the regular insulin vial to maintain proper vial pressure before withdrawing the dose.
B. Place the cap over the needle. Recapping needles increases the risk of needlestick injuries and is not necessary during the insulin preparation process. The needle should remain uncapped until both insulins are drawn and the injection is ready.
C. Withdraw 10 units of NPH insulin. Regular insulin should be drawn first to prevent contamination with NPH insulin. Since NPH is a cloudy suspension and regular insulin is clear, drawing regular insulin first ensures that the short-acting insulin remains unaltered.
D. Verify the dosage with another nurse. While verifying high-risk medications like insulin is important, the appropriate step after injecting air into the NPH vial is to proceed with injecting air into the regular insulin vial before withdrawing any insulin.

A. Hypotension B. Hearing loss C. Hyperthermia D. Constipation

Correct Answer is B

Explanation

A. Hypotension: Gentamicin is an aminoglycoside antibiotic that primarily affects the kidneys and auditory system rather than blood pressure. Hypotension is not a common adverse effect of gentamicin; however, dehydration related to nephrotoxicity could contribute to blood pressure fluctuations.
B. Hearing loss: Ototoxicity is a known adverse effect of gentamicin due to its accumulation in the inner ear, leading to damage of the cochlear and vestibular structures. Clients may report tinnitus, dizziness, or difficulty hearing, and prolonged exposure increases the risk of irreversible auditory impairment.
C. Hyperthermia: Fever is typically a sign of infection rather than an adverse effect of gentamicin. While aminoglycosides can cause fever in rare cases due to a drug-induced reaction, hyperthermia is not a common side effect and should prompt evaluation for worsening infection or another underlying cause.
D. Constipation: Gentamicin does not significantly affect gastrointestinal motility. While some antibiotics may cause gastrointestinal upset, nausea, or diarrhea, constipation is not a recognized adverse effect of gentamicin therapy.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

Correct Answer is B

Explanation

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