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 D
Explanation
The correct answer is d.
A. Informing the client that the anesthetic effect will last for approximately 6 hours is not the nurse's responsibility. The anesthesia provider usually communicates this information to the client.
B. Administering a 500 mL bolus of 5% dextrose in water prior to induction is the correct action.
Although preloading with a 500–1,000 mL bolus of isotonic crystalloid (e.g., Lactated Ringer’s) is recommended to mitigate hypotension, dextrose‑containing solutions (like D5W) are not used for this preload.
C. Having the client stand at the bedside with her arms at her side is not necessary for the administration of epidural analgesia. The client is usually positioned sitting up or lying on her side during the procedure.
D. Before initiating epidural analgesia, you must establish a baseline fetal heart rate and uterine contraction pattern with at least 20–30 minutes of continuous EFM to ensure fetal well‑being and detect any decelerations or atypical patterns.
Correct Answer is B
Explanation
The correct answer is B. Just above the symphysis pubis.
A. Just above the umbilicus: At the end of the first trimester, the uterus is still within the pelvic cavity, and fetal heart tones are typically not detectable above the umbilicus at this stage.
B. Just above the symphysis pubis: This is the correct placement for assessing fetal heart tones during the first trimester. The fetal heart is usually located low in the pelvis during early pregnancy, making it most easily heard just above the pubic bone.
C. The right lower quadrant: Fetal heart tones are typically assessed in the midline of the abdomen, and focusing on the lower quadrants may not be the optimal location, especially in the first trimester.
D. The left lower quadrant: Similar to the right lower quadrant, focusing on the lower quadrants may not be the most appropriate location for assessing fetal heart tones during the first trimester.
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