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

Exhibits

Based on the updated 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.

A.

Increase the oxytocin infusion to 13 mU/min

B.

Place client in a side-lying position

C.

Initiate bolus of primary IV fluids

D.

Apply oxygen at 10 L/min via venturi mask

E.

Perform sterile vaginal exam

F.

Assign a Bishop score

G.

Perform an amniotomy

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"None"},"G":{"answers":"B"}}

•    Increase the oxytocin infusion to 13 mU/min: This is an anticipated action. The client’s contractions are becoming more frequent and intense, and her cervix is dilating and effacing. Increasing the oxytocin infusion can help to further progress labor.
•    Place client in a side-lying position: This is an anticipated action. The side-lying position can help to improve maternal and fetal circulation and can also help to alleviate back pain.
•    Initiate bolus of primary IV fluids: This is an anticipated action. The client is in labor and may not be able to consume adequate fluids orally. Providing IV fluids can help to prevent dehydration.
•    Apply oxygen at 10 L/min via venturi mask: This is a nonessential action. The client’s respiratory rate and oxygen saturation are within normal limits, and she is not reporting any difficulty breathing.
•    Perform sterile vaginal exam: This is an anticipated action. Regular vaginal exams are necessary to assess the progress of labor, including changes in cervical dilation, effacement, and fetal station.
•    Assign a Bishop score: This is a nonessential action. The Bishop score is typically used to evaluate the readiness of the cervix for induction of labor. As the client is already in labor and her cervix is dilating and effacing, assigning a Bishop score is not necessary at this time.
•    Perform an amniotomy: This is a nonessential action. An amniotomy (artificial rupture of membranes) can be used to induce or augment labor, but it is not necessary if labor is progressing normally, as it appears to be in this client. Please note that these are potential actions and the healthcare provider should be informed immediately for further evaluation and management. It’s important to continue following the provider’s prescriptions and closely monitor the client’s condition.
 


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Related Questions

Correct Answer is A

Explanation

Choice A rationale
Assessing the fetal heart rate pattern is the priority nursing action following an amniotomy. This allows the nurse to monitor for signs of fetal distress, which can occur if the umbilical cord becomes compressed or prolapses as a result of the procedure.
Choice B rationale

Observing the color and consistency of the fluid can provide information about the well-being of the fetus, but it is not the priority action following an amniotomy.
Choice C rationale
Assessing the client’s temperature is important to monitor for signs of infection, but it is not the priority action following an amniotomy.
Choice D rationale
Evaluating the client for the presence of chills and increased uterine tenderness using palpation can help identify complications such as infection or uterine rupture, but it is not the priority action following an amniotomy.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

• Frequent urination: This is more likely to be associated with a UTI, as frequent urination is a common symptom of UTIs.
• Low back pain: This can be associated with both preterm labor and a UTI. Low back pain can be a sign of labor, and it can also be a symptom of a UTI.
• Temperature of 38.3°C (101°F): This is more likely to be associated with a UTI, as fever is a common symptom of infections, including UTIs.
• Strong urge to push: This is more likely to be associated with preterm labor, as an urge to push can be a sign of labor.
• Contractions every 1.5 minutes: This is more likely to be associated with preterm labor, as frequent contractions are a sign of labor.
• Pain level of 8 on a scale of 0 to 10: This can be associated with both preterm labor and a UTI. Severe pain can be a sign of labor, and it can also be a symptom of a UTI. Please note that these are potential associations and the healthcare provider should be informed immediately for further evaluation and management. It’s important to continue following the provider’s prescriptions and closely monitor the client’s condition.

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