A nurse is caring for a client who is 42 weeks of gestation
Nurses Notes
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 (SVE)
Assign a bishop score
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}
Increase the oxytocin infusion to 13 mu/min:
Anticipated: This action is anticipated. The nurse may consider adjusting the oxytocin infusion rate 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 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):
Nonessential: Based on the information provided, there is no indication for a sterile vaginal examination at this time. The cervical assessment was performed earlier at 0600, and 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 earlier at 0600, and the current focus is on monitoring the progress of labor with oxytocin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
"I should have a goal of maintaining my fasting blood glucose between 100 and 120." This statement does not indicate understanding of the teaching. Recommended target for fasting blood glucose levels during pregnancy in women with diabetes is typically lower, often between 60 and 90 mg/dL.
Choice B Reason:
"I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." This statement does not indicate understanding of the teaching . Exercising when blood glucose is already elevated to 250 or greater may not be safe. Exercise is generally recommended to help manage blood glucose levels, but the specific approach and timing should be discussed with the healthcare provider.
Choice C Reason:
"I will continue taking my insulin if I experience nausea and vomiting." This statement reflects an awareness of the importance of continuing insulin administration even if the client is experiencing nausea and vomiting. Consistent insulin management is crucial for maintaining blood glucose levels within the target range during pregnancy.
Choice D Reason:
"I will ensure that my bedtime snack is high in refined sugar." This statement does not indicate understanding of the teaching. Bedtime snacks should focus on providing sustained energy and stabilizing blood glucose levels. A snack high in refined sugar is not recommended as it can lead to fluctuations in blood glucose levels.
Correct Answer is A
Explanation
The correct answer is A.
A. Oligohydramnios: Oligohydramnios is a condition characterized by a lower-than-normal level of amniotic fluid in the uterus. Fetal assessment using electronic fetal monitoring may be indicated to monitor the well-being of the fetus, as oligohydramnios can be associated with fetal growth restriction and other complications.
B. Hyperemesis gravidarum: Hyperemesis gravidarum refers to severe nausea and vomiting during pregnancy. While it can be a challenging condition, it is not typically an indication for electronic fetal monitoring. Fetal monitoring is generally performed for conditions that directly impact the well-being of the fetus.
C. Leukorrhea: Leukorrhea refers to an increase in vaginal discharge, which is a common and normal occurrence during pregnancy. It is not an indication for electronic fetal monitoring, as it does not directly impact fetal well-being.
D. Periodic tingling of the fingers: Periodic tingling of the fingers is not typically an indication for fetal assessment using electronic fetal monitoring. It may be related to factors such as nerve compression or changes in circulation but is not a direct indication for monitoring the fetus.
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