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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.


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Related Questions

Correct Answer is C

Explanation

A. The number of sponges used during surgery is important but does not provide as much relevant information for postoperative care.

B. The intubation status is relevant to the immediate perioperative period, but the primary concern in hand-off is the current postoperative condition.

C. Estimated blood loss is an important clinical detail to convey during hand-off, as it may impact the client's recovery and need for monitoring.

D. The client’s position or professional role (e.g., being a board member) is not relevant to the care plan and should not be included in the hand-off report.

Correct Answer is B

Explanation

A. While noting changes in the medical record is important, it doesn’t specifically address communication between staff members.

B. Having interdisciplinary team meetings on a regular basis ensures that all healthcare providers involved in the client’s care are informed of the current treatment plan, goals, and changes. This promotes communication and collaboration across disciplines, which is especially important in the care of clients with conditions like expressive aphasia.

C. Recording progress in the nurses’ notes is important, but it alone does not foster active communication between different team members.

D. Posting swallowing precautions is important for the safety of the client but doesn’t address the need for better communication among the team.

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