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.

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 exam

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":"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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Correct Answer is D

Explanation

Choice A rationale
Placing pillows under the patient’s knees when resting in bed can actually increase the risk of thromboembolic disease by slowing blood flow and promoting clot formation.
Choice B rationale
Massaging the patient’s posterior lower legs is not recommended, especially if the patient is showing signs of a possible deep vein thrombosis (DVT), as it could dislodge a clot.

Choice C rationale
Applying warm, moist heat to the patient’s lower extremities is not typically recommended as a primary intervention for patients with a history of thromboembolic disease.
Choice D rationale
Having the patient ambulate can help prevent the formation of blood clots by promoting blood circulation.

A. Elevated blood pressure. B. Increased urine output. C. Vaginal discharge. D. Joint pain.

Correct Answer is A

Explanation

Choice A rationale
Elevated blood pressure is a key sign of preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys.
Choice B rationale
Increased urine output is not typically associated with preeclampsia. In fact, decreased urine output may be a sign of kidney problems associated with severe preeclampsia.
Choice C rationale
Vaginal discharge is common during pregnancy and is not typically associated with preeclampsia.
Choice D rationale
Joint pain is not typically associated with preeclampsia.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a patient who is 2 hours postpartum following a cesarean birth. The patient has a history of thromboembolic disease.Which nursing interventions should be included in the plan of care?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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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.