A nurse is caring for a client who is 42 weeks of gestation.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. "This medication promotes softening of the cervix."

A. Dinoprostone is a prostaglandin E2 analogue that is used to ripen the cervix by promoting softening and effacement. This is an important step in preparing the cervix for labor induction or augmentation.

B. Dinoprostone does not cause relaxation of the uterine muscles. Instead, it specifically works on the cervix to make it more favorable for labor.

C. Dinoprostone is not used to treat preeclampsi

A. It is primarily used for cervical ripening in the context of labor induction or augmentation.

D. Dinoprostone is not used to treat genital herpes simplex virus. It is specifically employed for its effects on cervical ripening and preparing the cervix for labor.

A. Discuss contraceptive options with the client and her partner. B. Repeat information to ensure client understanding. C. Listen to the client and her partner as they reflect upon the birth experience. D. Demonstrate to the client how to perform a newborn bath

Correct Answer is D

Explanation

A. Discuss contraceptive options with the client and her partner.Discussing contraceptive options typically occurs later in the postpartum period, often during follow-up visits. This is not a priority during the early taking-hold phase, when the mother is focused on learning to care for herself and her baby.

B. Repeat information to ensure client understanding.Repeating information and ensuring understanding is more critical during the taking-in phase, which occurs in the first 24 to 48 hours postpartum, when the mother is more passive, fatigued, and focused on her own recovery. In the taking-hold phase, the mother is typically more alert and eager to learn.

C. Listen to the client and her partner as they reflect upon the birth experience.Reflecting on the birth experience is more aligned with the taking-in phase, when the mother is focused on herself and may need emotional support in processing the experience.

D. Demonstrate to the client how to perform a newborn bath.In the taking-hold phase, the mother is ready to take responsibility for the care of her newborn and actively seeks guidance. Demonstrating how to bathe the newborn is an appropriate intervention, as it provides practical support and helps the mother gain confidence in newborn care.

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A nurse is caring for a client who is 42 weeks of gestation. Exhibits 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

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Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone gel. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?

Correct Answer is D

Explanation

A nurse is caring for a client who is 42 weeks of gestation Nurses Notes Exhibits 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.

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A nurse is caring for a client who is 42 weeks of gestation.

Exhibits

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