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? Click to specify whether the nurse's planned actions are anticipated, nonessential, or contraindicated
Increase the oxytocin infusion to 13 mu/min
Place client in a side lying position
Initiate bolus of primary IV fluids
Apply oxygen at 10 L/Min via venturi mask
Perform sterile vaginal examination (SVF)
Assign a bishop score
Perform an amniotomy
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"},"G":{"answers":"A"}}
Increase the oxytocin infusion to 13 mu/min:
Anticipated: This action is anticipated. Adjusting the oxytocin infusion rate may be appropriate based on the progress of labor and the response to the current infusion rate.
Place client in a side-lying position:
Anticipated: Placing the client in a side-lying position is an anticipated action. This position can enhance fetal oxygenation and blood flow, especially if there are concerns about fetal well-being.
Initiate a bolus of primary IV fluids:
Anticipated: Initiating a bolus of primary IV fluids is an anticipated action. Adequate hydration is important during labor, and a bolus may be initiated if there are signs of dehydration or as part of the overall management plan.
Apply oxygen at 10 L/Min via a venturi mask:
Anticipated: Applying oxygen at 10 L/min via a venturi mask is an anticipated action. Oxygen may be administered to the mother to improve oxygenation and, consequently, fetal oxygenation.
Perform sterile vaginal examination (SVE):
Contraindicated: There is no indication for a sterile vaginal examination (SVE) at this time based on the information provided. Frequent unnecessary SVEs can increase the risk of infection.
Assign a Bishop score:
Nonessential: Assigning a Bishop score is not essential at this point. The client's cervical status was assessed during admission, and the current focus is on monitoring the progress of labor with oxytocin.
Perform an amniotomy:
Anticipated: Depending on the clinical situation, performing an amniotomy (artificial rupture of membranes) may be anticipated as part of the labor induction process. However, the decision should be based on the overall assessment and progress of labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Confirming the newborn's Apgar score is important for assessing the newborn's overall condition, but it may not be the first priority.
Choice B Reason:
Verifying the newborn's identification is appropriate. Ensuring accurate identification is a crucial step in newborn care to prevent errors and ensure that interventions are carried out on the correct infant.
Choice C Reason:
Administering vitamin K is a standard practice but can wait until after the newborn's identification is confirmed.
Choice D Reason:
Determining obstetrical risk factors is part of the overall assessment but is not the immediate priority in this situation.
Correct Answer is D
Explanation
A. Decreased vaginal discharge is not typically associated with the onset of labor. In fact, an increase in vaginal discharge may be observed as the cervix begins to soften and efface.
B. Weight gain of 0.5 to 1.5 kg is not a specific sign that precedes labor. Weight gain during late pregnancy is more related to fluid retention, and it does not necessarily indicate imminent labor.
C. Urinary retention is not a common sign that precedes labor. However, increased pressure on the bladder from the descending fetus may lead to more frequent urination rather than retention.
D. A surge of energy is known as the "nesting instinct" and is a common sign that precedes labor. Some women experience a burst of energy and motivation to prepare for the upcoming birth.
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