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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

The correct answer is A. Two arteries and one vein.

A. Two arteries and one vein is the typical composition of the umbilical cord vessels. The umbilical arteries carry deoxygenated blood and waste products away from the fetus, while the umbilical vein carries oxygenated blood and nutrients to the fetus.

B. Two veins and one artery is not the usual configuration of the umbilical cord vessels. The presence of two veins is atypical.

C. One artery and one vein is an abnormal finding and may be associated with certain congenital anomalies or fetal abnormalities. This configuration is not the norm.

D. Two arteries and two veins is not a standard or physiological composition of the umbilical cord. The typical configuration is two arteries and one vein.

A. Inform the client the anesthetic effect will last for approximately 6 hr B. Administer a 500 mL bolus of 5% dextrose in water prior to Induction C. Have the client stand at the bedside with her arms at her side. D. Obtain a 30 min electronic fetal monitoring (CFM) strip prior to induction

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.

View Question and Answer

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

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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?

Correct Answer is A

Explanation

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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.

A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone gel. Which of the following statements should the nurse include in the teaching?

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as -1. Which of the following interpretations of this finding should the nurse make?

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is scheduled to receive intravenous oxytocin for the induction of labor. The client has a Bishop score of 8 which of the following findings should the nurse expect?

A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect?

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagin

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.