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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

A) Fetal head compression: Fetal head compression would typically result in variable decelerations, not late decelerations.
B) Umbilical cord compression: Umbilical cord compression is associated with variable decelerations, not late decelerations.
C) Uteroplacental insufficiency: Late decelerations occur due to decreased blood flow and oxygen supply to the fetus, which can be caused by uteroplacental insufficiency. This condition can lead to fetal hypoxia during contractions.
D) Maternal bradycardia: Maternal bradycardia would not directly cause late decelerations in the fetal heart rate.

A. "It occurs during the first trimester and near the end of the pregnancy." B. "It's a minor inconvenience, which you should ignore." C. "There is no way to predict how long it will last in each individual client." D. "In most cases, it only lasts until the 12th week, but it will continue if you have poor bladder tone."

Correct Answer is A

Explanation

Choice A: Urinary frequency is a common symptom during pregnancy, especially in the first trimester and near the end of the pregnancy. During the first trimester, it is mainly due to

hormonal changes and increased blood flow to the pelvic area. In the later stages, it is caused by the growing uterus putting pressure on the bladder.

Choice B: Dismissing the client's concern as a minor inconvenience is not appropriate and may disregard the client's experience.

Choice C: While it is true that each individual client's experience may vary, it is important to provide the client with information regarding common patterns.

Choice D: Providing accurate information about the duration of urinary frequency is important. While it may last until the 12th week for many women, it does not continue throughout the entire pregnancy for most individuals, regardless of bladder tone.

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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

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Correct Answer is C

Explanation

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Correct Answer is A

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