A nurse is assisting with the care of a client who is in active labor.

Admission Assessment.

1130: Client admitted to labor and delivery.

Gravida 1, para 0 at 40. weeks of gestation.

Client presents with contractions every 5 to. 6 min, 30 to 40 seconds duration, 2+ intensity.

Client reports their water broke and the fluid was clear.

Positive for group B. streptococcus B-hemolytic at 37 weeks.

Sterile vaginal examination by RN. Cervix 5 cm dilated, 50% effaced.

0 station.

The nurse is assisting with the care of the client following the insertion of an epidural.

For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.

Place the client in left lateral position.

Decrease the IV flow rate.

Assist with administration of ampicillin I.

Monitor fetal heart rate.

Request a prescription for ephedrine.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"None"}}

Nursing Intervention	Essential	Contraindicated?	Explanation
Place the client in left lateral position.	Yes	No	This position improves maternal and fetal blood flow and reduces the risk of hypotension.
Decrease the IV flow rate.	No	Yes	This intervention is contraindicated because the client may need fluid boluses to maintain adequate blood pressure and hydration.
Assist with administration of ampicillin I.	Yes	No	This intervention is essential because the client is positive for group B streptococcus and needs antibiotic prophylaxis to prevent neonatal infection.
Monitor fetal heart rate.	Yes	No	This intervention is essential because epidural analgesia can affect uterine contractility and fetal oxygenation.
Request a prescription for ephedrine.	No	No	This intervention is neither essential nor contraindicated. Ephedrine is a vasopressor that can be used to treat hypotension caused by epidural analgesia, but it is not routinely prescribed unless the client develops symptoms of hypotension.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

Here are some possible answers: Response to other clients: This finding could indicate that the client’s condition has improved if they are more cooperative and respectful of others, or that it has declined if they are more hostile and paranoid of others. Sleep patterns: This finding could indicate that the client’s condition has improved if they are sleeping more regularly and peacefully, or that it has declined if they are sleeping less or having nightmares.

Hygiene patterns: This finding could indicate that the client’s condition has improved if they are taking care of their personal hygiene and appearance, or that it has declined if they are neglecting or refusing to do so. Interaction with the nurse: This finding could indicate that the client’s condition has improved if they are more trusting and communicative with the nurse, or that it has declined if they are more suspicious and withdrawn from the nurse.

A. Boggy fundus 3 fingerbreadths above the umbilicus. B. Client report of uterine cramping. C. Saturation of perineal pad in 15 min. D. Client report of burning with urination.

Correct Answer is B

Explanation

Choice A rationale:

A boggy fundus 3 fingerbreadths above the umbilicus is not an expected finding after receiving oxytocin for excessive vaginal bleeding. This finding could indicate uterine atony, which is a concern, but it is not a typical immediate response to oxytocin.

Choice B rationale:

The client reporting uterine cramping is an expected finding after receiving oxytocin. Oxytocin is often administered to stimulate uterine contractions and reduce bleeding, so uterine cramping is a positive response to the medication.

Choice C rationale:

Saturation of perineal pad in 15 minutes is not an expected finding after receiving oxytocin. Excessive bleeding would be a concern, and the nurse should monitor for signs of hemorrhage.

Choice D rationale:

The client reporting burning with urination is not an expected finding related to oxytocin administration. This symptom could be indicative of a urinary tract infection or another issue unrelated to oxytocin. It should be assessed and addressed separately.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding.Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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