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,D
Choice A: There is no indication to increase the oxytocin infusion rate, as the fetal heart rate tracing is currently Category 3, which indicates abnormal fetal heart rate patterns.
Choice B: Initiation of a bolus of primary IV fluids is indicated to improve placental perfusion and maternal hydration in response to the abnormal fetal heart rate tracing.
Choice C: Placing the client in a sidelying position can help improve uteroplacental perfusion, especially if there is evidence of fetal distress.
Choice D: Applying oxygen at 10 L/min via a venturi mask is indicated for Category 3 fetal heart rate tracings to improve fetal oxygenation.
Choice E: Performing a sterile vaginal examination (SVE) is not indicated based on the assessment findings provided. SVE is typically done for cervical assessments and labor progression but is not relevant in this situation where fetal wellbeing is the main concern.
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Related Questions
Correct Answer is B
Explanation
A. Maintain the client in the lithotomy position: The lithotomy position is not typically
maintained during the active phase of labor. It is used during the pushing stage (second stage) of labor.
B. Encourage the client to empty her bladder every 2 hr: A full bladder can impede fetal descent and progress during labor, so encouraging the client to empty her bladder regularly is essential.
C. Remind the client to bear down with each contraction: Bearing down during the active phase of labor is not appropriate, as it may lead to premature pushing and cervical swelling.
D. Perform vaginal examinations frequently: Frequent vaginal examinations can increase the risk of infection and should be minimized during labor.
Correct Answer is B
Explanation
A. "I will monitor my weight gain during the remaining months."
Correct: Monitoring weight gain during pregnancy is an appropriate action as it helps to ensure the baby's growth and overall health.
B. "I will use only nonprescription medications while pregnant."
Incorrect: This statement indicates a need for further teaching. Nonprescription medications may not be safe during pregnancy, as some overthecounter drugs can potentially harm the
fetus. It's essential for pregnant women to consult their healthcare provider before taking any medications.
C. "I will tell my doctor before using home remedies for nausea."
Correct: This statement shows the client's understanding that it's important to consult with their healthcare provider before using any home remedies during pregnancy, as some
remedies may not be safe for the developing fetus.
D. "I will reduce my stress level."
Correct: Managing stress during pregnancy is beneficial for both the mother and the baby. It indicates a good understanding of selfcare during pregnancy.
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