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 A
Explanation
The correct answer is A. "It sounds like you are feeling sad that things didn't go as planned."
A. This response reflects empathy and acknowledges the client's feelings without judgment. It validates the client's emotions and provides an opportunity for her to express her feelings further.
B. "Maybe next time you can have a vaginal delivery" is not an appropriate response as it assumes that the client will or should have another pregnancy and may have a vaginal delivery. It is more important to address the current emotions and experience.
C. "At least you know you have a healthy baby" dismisses the client's feelings of disappointment. While the health of the baby is important, it's essential to acknowledge and validate the client's emotional experience.
D. "You can resume sexual relations sooner than if you had delivered vaginally" is not relevant to the client's expressed disappointment about the mode of delivery. It may not be an appropriate or comforting statement given the context.
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.
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