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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C.
A. Calcium: While calcium is important for bone health, it is not specifically increased during early pregnancy. Adequate calcium intake is important throughout pregnancy, but the focus on increased intake typically occurs later in pregnancy to support fetal bone development.
B. Vitamin E: Vitamin E is important for overall health, but there is not a specific emphasis on increasing vitamin E intake in the early stages of pregnancy. It is generally included as part of a balanced diet.
C. Iron: This is the correct answer. Iron needs increase during pregnancy to support the increased blood volume and prevent iron-deficiency anemia. Adequate iron is crucial for the transport of oxygen to the developing fetus.
D. Vitamin D: While vitamin D is important for bone health and immune function, its increase is not specific to the early stages of pregnancy. Adequate vitamin D intake is essential throughout pregnancy, but it is not singled out as needing a significant increase at 8 weeks of gestation.
Correct Answer is A
Explanation
The correct answer is A. Variable decelerations are due to umbilical cord compression.
A. Variable decelerations are often associated with umbilical cord compression. This compression can occur when the umbilical cord is briefly compressed or squeezed, leading to transient decreases in fetal heart rate.
B. Variable decelerations are not typically a result of the administration of IV narcotic analgesics. They are more commonly associated with cord compression or other factors affecting fetal oxygenation.
C. Variable decelerations are not generally caused by uteroplacental insufficiency. Uteroplacental insufficiency is more commonly associated with late decelerations.
D. Variable decelerations are not primarily related to fetal head compression. While head compression can cause certain types of decelerations, variable decelerations are specifically associated with umbilical cord compression.
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