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.

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

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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

Easier to breathe and less short of breath: The client reports improvement in breathing, stating it is easier to breathe and they are less short of breath. This suggests that the respiratory status is improving, which is a key indicator of progress.

Lung sounds still diminished with crackles, but no wheezes detected: While lung sounds are still diminished and crackles remain, the absence of wheezes indicates that the client’s condition is stabilizing. Wheezing would be concerning for bronchospasm or worsening respiratory distress, so the absence of this finding is a positive development.

Oxygen saturation 92%: The client’s oxygen saturation has improved from 88% on room air (Day 1) to 92% on 1 L/min of oxygen. Although still slightly below the target of 94%–98%, this improvement is a sign that oxygenation is improving with the current treatment.

Pleuritic chest pain reduced to 3/10: The client's report of pleuritic chest pain has decreased from 6/10 to 3/10. This reduction in pain indicates a positive response to treatment and the improvement of the underlying infection.

Increased oral intake (drinking 2 L/day): The client is drinking 2 L of fluids per day, which indicates adequate hydration and may help with recovery, particularly in the context of respiratory and infection management.

Normal urine output (200 mL of clear yellow urine): The client’s urine output appears adequate, and the urine is clear and yellow, which suggests proper hydration and normal renal function, supporting overall recovery.

A. Steatorrhea B. Tinnitus C. Dysphagia D. Fever

Correct Answer is D

Explanation

A. Steatorrhea (fatty stools) is not typically associated with pneumonia; it is more commonly linked to gastrointestinal disorders.

B. Tinnitus (ringing in the ears) is not a common symptom of pneumonia but may be related to ear infections or other conditions.

C. Dysphagia (difficulty swallowing) is not typically a hallmark symptom of pneumonia, though it can occur in severe cases if there is aspiration.

D. Fever is a common symptom of bacterial pneumonia due to the body’s response to infection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

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