How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client.

Exhibits

A nurse is continuing care for the client.

For each potential nursing action, click to specify if the nursing action 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.

A.

Obtain consent for cesarean birth

B.

Provide intermittent fetal heart rate monitoring

C.

Administer oxygen 10 L via face mask

D.

Prepare the client for an amnioinfusion

E.

Initiate IV bolus lactated Ringer’s

F.

Insert a urinary catheter

Answer and Explanation

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

Nursing action

Anticipated

Contraindicated

Obtain consent for cesarean birth

✅

 

Provide intermittent fetal heart rate monitoring

✅

 

Administer oxygen 10 L via face mask

✅

 

Prepare the client for an amnioinfusion

 

✅

Initiate IV bolus lactated Ringer’s

✅

 

Insert a urinary catheter

 

✅

Rationale:

Obtain consent for cesarean birth: This is anticipated because the client is presenting with uterine contractions, vaginal bleeding, and abdominal pain, which may indicate complications such as placental abruption or abnormal placental attachment, potentially requiring a cesarean birth for the safety of both the mother and fetus.

 

Provide intermittent fetal heart rate monitoring: This is anticipated as it is essential to monitor fetal well-being, especially with the reported minimal fetal heart rate variability and potential for fetal distress.

Administer oxygen 10 L via face mask: This is anticipated to improve oxygenation, especially if there is a risk of fetal distress or compromised perfusion due to maternal blood loss.

Prepare the client for an amnioinfusion: This is contraindicated in the setting of vaginal bleeding and suspected placental abruption, as amnioinfusion is typically used for conditions such as oligohydramnios, and it could increase the risk of additional complications in this case.

Initiate IV bolus lactated Ringer’s: This is anticipated as the client has signs of hypovolemic shock due to blood loss, and an IV bolus would be necessary to improve fluid volume and blood pressure.

Insert a urinary catheter: This is contraindicated unless clinically necessary, as urinary catheterization may not be indicated in the immediate management of placental issues or bleeding complications without further evaluation, and it could introduce an infection risk.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is A

Explanation

A. Ensuring the client has an alert system addresses immediate safety and the risk of falls, which is a priority for a client with mobility impairments.

B. Support groups are beneficial for emotional support but are secondary to physical safety.

C. Transportation resources are important but do not address the urgent need for fall prevention.

D. Home physical therapy is important for recovery but does not immediately ensure the client's safety.

Correct Answer is ["C","E","G"]

Explanation

  1. Difficulty sleeping: This can be a side effect of fluoxetine, which can cause insomnia in some individuals.
  2. Frequent headaches: Headaches are a common side effect of many antidepressants, including fluoxetine.
  3. BP 169/91 mm Hg: Elevated blood pressure can be an adverse effect of fluoxetine, especially if the client has a history of hyperlipidemia.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register