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 B
Explanation
The correct answer is B. Position the client with one hip elevated.
A. Having the client void is a good practice, but it is not the priority action in this situation. The client's vital signs suggest a potential issue with uteroplacental perfusion, and repositioning the client should be the priority.
B. Positioning the client with one hip elevated is the priority action.
The vital signs, specifically the low blood pressure, may be indicative of aortocaval compression (supine hypotension). Elevating one hip helps alleviate this compression, improving blood flow and potentially addressing the decreased blood pressure.
C. Asking the client if she needs pain medication is important, but repositioning the client takes precedence due to the potential issue with blood pressure and uteroplacental perfusion.
D. Notifying the provider is important, but repositioning the client to improve blood flow should be done first. The provider may be notified afterward based on the client's response and ongoing assessment.
Correct Answer is A
Explanation
The correct answer is A. Blood pressure 80/56 mm Hg.
A. A blood pressure of 80/56 mm Hg is the priority finding. Opioid analgesia can cause hypotension, and addressing low blood pressure is crucial to prevent maternal and fetal complications. The nurse should notify the healthcare provider promptly and implement interventions to improve blood pressure.
B. Profuse itching is a common side effect of opioids and is generally not considered a priority unless it becomes severe or is accompanied by other concerning symptoms.
C. A temperature of 38.2°C (100.8°F) may indicate a fever, but addressing hypotension takes precedence. Elevated temperature can be further assessed but is not the priority in this scenario.
D. The client reporting weakness of the lower extremities is a concerning symptom, but the priority is to address hypotension first, as it could be related to opioid-induced hypotension.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.