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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 C

Explanation

Choice A: At 7 cm dilation, the client is in active labor, and assisting her into a more comfortable position may not be appropriate at this stage. It is essential to observe for signs of impending birth and assess the progress of labor.

Choice B:Crowning is assessed only once full dilation occurs. At 7 cm, this is premature and distracts from interventions that prevent injury from early pushing.

Choice C:Panting or blowing helps suppress the urge to push until full dilation, protecting the cervix and reducing complications. This is the evidence-based intervention recommended in labor management guidelines.

Choice D: While emptying the bladder is generally recommended during labor to provide more room for the baby to descend, the client's current urge to push suggests that the baby is likely in a lower position, and it might not be safe or feasible to move the client to the bathroom.

A. Vomiting B. Tachycardia C. Hypotension D. Respiratory depression

Correct Answer is C

Explanation

A) Vomiting: Vomiting is not a common complication of epidural anesthesia. Nausea can occur but is not directly related to the epidural block itself.
B) Tachycardia: Tachycardia is not a common complication of epidural anesthesia. It may occur due to other factors, but it is not directly associated with the epidural block.
C) Hypotension: Hypotension (low blood pressure) is a common complication of epidural anesthesia. The epidural can cause vasodilation, leading to a drop in blood pressure. It is essential to monitor the client's blood pressure and intervene promptly if hypotension occurs.
D) Respiratory depression: Respiratory depression is not a typical complication of epidural anesthesia. Epidural anesthesia mainly affects the lower part of the body and does not usually cause significant respiratory effects.

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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

Correct Answer is C

Explanation

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?

Correct Answer is C

Explanation

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