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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E","F","G"]
Explanation
Choice A rationale:
Performing a vaginal examination every 12 hours is not necessary in this case. The client is not in labor and there are no indications of any complications that would require frequent vaginal examinations.
Choice B rationale:
The client’s symptoms of severe headache, +3 pitting edema in bilateral lower extremities, and a patellar reflex of 4+ without the presence of clonus are indicative of severe preeclampsia. Antihypertensive medications are often used to manage high blood pressure in preeclampsia.
Choice C rationale:
Betamethasone is a corticosteroid that is given to pregnant women who are at risk of delivering prematurely to help mature the baby’s lungs. Given that the client is at 31 weeks of gestation and has had a previous preterm birth, administering betamethasone would be appropriate.
Choice D rationale:
A low-stimulation environment can help reduce blood pressure and prevent seizures in clients with preeclampsia.
Choice E rationale:
Bed rest can help lower blood pressure and improve blood flow to the placenta, which can be beneficial for the baby.
Choice F rationale:
Monitoring intake and output every hour can help assess kidney function, which can be affected by preeclampsia.
Choice G rationale:
A 24-hour urine specimen can provide information about protein levels in the urine, which can indicate the severity of preeclampsia. It’s important to note that normal ranges for lab parameters can vary slightly depending on the lab, but generally, protein levels in a 24-hour urine specimen should be less than 300 mg. Pitting edema is usually graded on a scale of 1+ (mild) to 4+ (severe), and a patellar reflex of 4+ is considered hyperactive and may indicate nervous system hyperexcitability seen in severe preeclampsia or eclampsia.
Correct Answer is B
Explanation
Correct answer is: B. 16 lb.
Choice A rationale: 32 lb. is too much weight gain for a client whose prepregnancy BMI was 30.5. According to the Institute of Medicine (IOM) guidelines, obese women (BMI greater than or equal to 30) should only gain 11 to 20 lb.during pregnancy12.Excessive weight gain can increase the risk of gestational diabetes, hypertension, cesarean delivery, and postpartum weight retention1.
Choice B rationale: 16 lb. is an acceptable weight gain for a client whose prepregnancy BMI was 30.5. This is within the recommended range of 11 to 20 lb.for obese women (BMI greater than or equal to 30) by the IOM guidelines12.Adequate weight gain can help ensure optimal fetal growth and development, as well as maternal health1.
Choice C rationale: 24 lb. is too much weight gain for a client whose prepregnancy BMI was 30.5. This exceeds the recommended range of 11 to 20 lb.for obese women (BMI greater than or equal to 30) by the IOM guidelines12.Excessive weight gain can increase the risk of gestational diabetes, hypertension, cesarean delivery, and postpartum weight retention1.
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