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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).

Answer and Explanation

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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Correct Answer is A

Explanation

A. A surge of energy: Some women experience a sudden burst of energy, often referred to as a "nesting" instinct, shortly before the onset of labor.
B. Urinary retention: Urinary frequency and urgency are more common before labor, not urinary retention.
C. Decreased vaginal discharge: Before labor, there might be an increase in vaginal discharge, often thick and pinkish, known as the "bloody show."
D. Weight gain of 0.5 to 1.5 kg: Weight gain is not typically associated with the onset of labor.

A. "Don't worry. You will be fine once the baby is born." B. "Ambivalent feelings are quite common for women early in pregnancy." C. "Perhaps you should see a counselor to discuss these feelings further." D. "Have you spoken to your mother about these feelings?"

Correct Answer is B

Explanation

Choice A: This response is dismissive and does not validate the client's feelings. It may not address the client's concerns effectively.

Choice B: This response validates the client's feelings and reassures her that ambivalent feelings about pregnancy are common. It provides a supportive approach and normalizes her emotions.

Choice C: While counseling might be helpful for some clients, suggesting it immediately without further assessment of the client's needs may not be the most appropriate response at this stage.

Choice D: Encouraging the client to discuss her feelings with her mother may not be suitable, as the client might prefer professional support or may not have a positive relationship with her

mother. It is essential to avoid making assumptions about the client's support system and address her concerns empathetically.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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