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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Correct Answer is C

Explanation

A. Draw blood specimens for culture and sensitivity: Incorrect. Blood cultures are not routinely required for cardiac catheterization.

B. Administer nitroglycerin 0.4 mg SL 30 min before the procedure: Incorrect. Nitroglycerin is not typically administered before a cardiac catheterization unless specifically ordered.

C. Obtain a CBC with differential: A complete blood count (CBC) is necessary before a cardiac catheterization to assess for potential bleeding risks, infection, or anemia.

D. Transport the client to radiology for a CT scan: Incorrect. Cardiac catheterization is performed in a specialized cardiac catheterization lab, not in radiology.

Correct Answer is []

Explanation

Potential condition: Deep vein thrombosis

Based on the provided information, the client is most likely experiencing Deep Vein Thrombosis (DVT). This is suggested by the client's history of smoking, lack of exercise, obesity, recent surgery, and the fact that they are not wearing sequential compression devices due to discomfort.

Actions to Take

Request a prescription for a lower-extremity Doppler flow study: This will help confirm the presence of a blood clot in the deep veins.
Assess for Homan's sign: This is a clinical test used to check for DVT, although it's not always reliable.

Parameters to Monitor

Signs of bleeding after anticoagulation initiation: This is crucial because anticoagulants are often used to treat DVT, and monitoring for bleeding is essential.
PT/INR and platelet count: These parameters help assess the effectiveness and safety of anticoagulation therapy.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client to undergo a cardiac catheterization. Which of the following tasks should the nurse perform prior to the procedure?

Correct Answer is C

Explanation

Correct Answer is []

Explanation

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