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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: It is not accurate to say that a repeat cesarean birth will always be safer. The decision for a repeat cesarean or a trial of labor after cesarean (TOLAC) depends on various factors, including the client's medical history and the type of incision used in the previous cesarean.
Choice B: While there are multiple factors to consider, the nurse can still provide general information about the possibility of attempting a vaginal birth after cesarean (VBAC).
Choice C: While focusing on the health of the newborn is important, the client's question about the possibility of a future VBAC can be addressed without dismissing her concerns.
Choice D: The type of incision used in the previous cesarean birth (such as low transverse incision) is a significant factor in determining the eligibility for a VBAC in subsequent pregnancies. Clients with certain types of incisions may have a higher likelihood of success with a VBAC.
Correct Answer is A
Explanation
A. Fetal position is persistent occiput posterior: The occiput posterior position (the back of
the baby's head facing the mother's back) can lead to a more challenging and prolonged labor with intense back pain.
B. Fetal attitude is in general flexion: Flexion is the normal fetal attitude for birth and does not contribute to a difficult labor with backache.
C. Fetal lie is longitudinal: Longitudinal lie refers to the baby's position along the mother's spine, but it doesn't specify the position of the baby's back, so it is not directly related to backache.
D. Maternal pelvis is gynecoid: Gynecoid pelvis is the most favorable pelvis shape for childbirth, so it is not likely to cause difficult labor with severe backache.
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