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

Nurses Notes

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 (SVE)

Assign a bishop score

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is B. An excessive amount of amniotic fluid is present.

A. Polyhydramnios is primarily characterized by an increased volume of amniotic fluid, and it is not directly linked to congenital anomalies, growth restriction, or fetal distress. However, it can be associated with certain conditions that affect fetal swallowing or the production of amniotic fluid.

B. Correct. Polyhydramnios refers to an abnormal increase in the amount of amniotic fluid surrounding the fetus. This condition can result from various factors, such as fetal anomalies, maternal diabetes, or gastrointestinal malformations in the fetus that affect the swallowing of amniotic fluid.

C. An elevated level of alpha-fetoprotein (AFP) in the amniotic fluid is associated with neural

tube defects, not polyhydramnios.

D. Carrying more than one fetus (multifetal gestation) can be associated with an increased risk of polyhydramnios due to factors such as increased fetal urine production, but the presence of polyhydramnios does not necessarily indicate a multifetal pregnancy.

A. "You can miss your period for several other reasons. Describe your typical menstrual cycle B. "If you have been sexually active and haven't used protection it is likely that you are pregnant C. "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet? D. "Because you have missed your period, you should try taking a home pregnancy test before you start worrying

Correct Answer is A

Explanation

Choice A Reason:

"You can miss your period for several other reasons. Describe your typical menstrual cycle." This response acknowledges that a missed period can result from various factors other than pregnancy, such as stress, changes in weight, hormonal fluctuations, or certain medical conditions. Understanding the client's typical menstrual cycle can help the nurse gather more information about potential reasons for the late period.

Choice B Reason:

"If you have been sexually active and haven't used protection, it is likely that you are pregnant. “This response assumes pregnancy without exploring other possibilities or the client's individual situation.

Choice C Reason:

"Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" While considering other signs of pregnancy is reasonable, focusing on abdominal enlargement may not be the most accurate early indicator, and it's essential to explore a broader range of symptoms.

Choice D Reason:

"Because you have missed your period, you should try taking a home pregnancy test before you start worrying. "While suggesting a home pregnancy test is reasonable, it may be more beneficial to gather additional information about the client's menstrual cycle and potential symptoms before jumping directly to a test.

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A nurse is caring for a client who is 42 weeks of gestation Nurses Notes 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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Explanation

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

Nurses Notes

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.