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. Slow the client's rate of breathing. B. Decrease the rate of infusion of the maintenance IV Solution C. Increase the rate of infusion of the IV oxytocin D. Discontinue the infusion of the IV oxytocin

Correct Answer is D

Explanation

The correct answer is D.

A. Slowing the client's rate of breathing is not directly related to the observed uniform decelerations. The primary concern is the fetal heart rate pattern.

B. Decreasing the rate of infusion of the maintenance IV solution is not the appropriate intervention for addressing the observed fetal heart rate decelerations. The focus should be on the oxytocin infusion rate.

C. Increasing the rate of infusion of the IV oxytocin is not the appropriate action.

The patient is already experiencing frequent and strong contractions, and increasing the oxytocin rate can exacerbate the decelerations and compromise fetal well-being.

D. Discontinuing the infusion of the IV oxytocin is the correct action.

The observed uniform decelerations are likely related to oxytocin-induced hyperstimulation of the uterus. Stopping or decreasing the oxytocin infusion allows for the uterine activity to decrease, potentially improving fetal heart rate patterns.

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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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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