A nurse is caring for a client who is 42 weeks of gestation. Based on the assessment findings, which of the following actions should the nurse plan to take? (Select all that apply.)
Increase the oxytocin infusion to 13 mu/min.
Initiate a bolus of primary IV fluids.
Place the client in a sidelying position.
Apply oxygen at 10 L/min via a venturi mask.
Perform a sterile vaginal examination (SVE).
Correct Answer : B,C,E
The correct answer is B, C, and D.
Choice A: Increase the oxytocin infusion to 13 mu/min
Increasing the oxytocin infusion is not indicated in this scenario. Oxytocin is used to induce or augment labor, but if the fetal heart rate tracing is abnormal (Category 3), increasing oxytocin could exacerbate fetal distress. The priority is to stabilize the fetal condition before considering increasing oxytocin.
Choice B: Initiate a bolus of primary IV fluids
Initiating a bolus of primary IV fluids is appropriate. This action helps improve placental perfusion and maternal hydration, which can be beneficial in response to abnormal fetal heart rate tracings. Adequate hydration can enhance uteroplacental blood flow and improve fetal oxygenation.
Choice C: Place the client in a sidelying position
Placing the client in a sidelying position is recommended. This position can improve uteroplacental perfusion and fetal oxygenation, especially if there are signs of fetal distress. It helps to alleviate pressure on the inferior vena cava, enhancing blood flow to the placenta.
Choice D: Apply oxygen at 10 L/min via a venturi mask
While oxygen may be indicated for fetal distress, the correct method is usually a non-rebreather mask at 10 L/min, not a venturi mask. A venturi mask delivers more precise oxygen concentrations but not high-flow oxygen, which is needed in this scenario.
Choice E: Perform a sterile vaginal examination (SVE)
A vaginal exam assesses labor progression, cervical dilation, station, and fetal position. This is important for determining whether labor is progressing appropriately or whether further interventions are needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) "It is used to treat genital herpes simplex virus.": This statement is incorrect. Dinoprostone (Cervidil) gel is not used to treat genital herpes simplex virus; it is used in obstetrics to ripen the cervix and prepare it for labor induction.
B) "This medicine causes relaxation of the uterine muscles.": While dinoprostone is a prostaglandin that can induce uterine contractions, its primary use in this context is cervical ripening, not uterine muscle relaxation.
C) "This medication is used to treat preeclampsia.": Dinoprostone is not used to treat preeclampsia. It is used for cervical ripening and labor induction in appropriate situations.
D) "This medication is used to ripen, or soften, the cervix.": This is the correct answer. Dinoprostone (Cervidil) gel is used to ripen the cervix, making it more favorable for labor induction, especially in cases where the cervix is not yet fully dilated or effaced.
Correct Answer is A
Explanation
A: Quickening, which refers to the sensation of the baby moving in the womb, is considered a presumptive sign of pregnancy. It is called "presumptive" because it is subjective and can be attributed to other causes, such as gas or gastrointestinal movements.
B: Positive signs of pregnancy are those that are attributed only to the presence of a fetus, such as fetal heartbeat or visualization on ultrasound. Feeling the baby move (quickening) is not specific enough to confirm pregnancy on its own.
C: Probable signs of pregnancy are more objective and can be detected by a healthcare provider, such as a positive pregnancy test or ballottement (rebounding of the fetus against the examiner's fingers). Feeling the baby move is not a probable sign as it is subjective and can be attributed to other factors.
D: "Potential sign of pregnancy" is not a recognized classification in pregnancy signs.
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