A nurse is caring for a client who is at 38 weeks of gestation and has a score of 10 on her biophysical profile. Which of the following actions should the nurse take?
Administer oxygen and notify the provider.
Assure the client that the score is within the expected range.
Offer the client orange juice and repeat the assessment in 1 hr.
Assist the client into a side-lying position.
The Correct Answer is B
The correct answer is choice B. Assure the client that the score is within the expected range.
Choice A rationale:
Administering oxygen and notifying the provider is not necessary for a biophysical profile (BPP) score of 10. A score of 10 indicates that the fetus is well-oxygenated and there are no signs of distress.
Choice B rationale:
A BPP score of 10 is considered normal and reassuring, indicating that the fetus is well-oxygenated and there are no signs of distress. Therefore, the nurse should assure the client that the score is within the expected range.
Choice C rationale:
Offering the client orange juice and repeating the assessment in 1 hour is not necessary for a BPP score of 10. This action might be considered if the score were lower and there was a need to reassess fetal well-being.
Choice D rationale:
Assisting the client into a side-lying position is not required for a BPP score of 10. This position is typically recommended to improve uteroplacental blood flow in cases of fetal distress or lower BPP scores.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale :
The correct answer is A. Calcium gluconate. The nurse should administer calcium gluconate in this situation because the client's respiratory rate is 8/min, which indicates respiratory depression. Magnesium sulfate is known to cause respiratory depression as a side effect, and calcium gluconate is the antidote for magnesium sulfate toxicity. Calcium gluconate works by antagonizing the effects of magnesium on the neuromuscular junction and restoring normal respiratory function. Prompt administration of calcium gluconate can help reverse respiratory depression and prevent further complications.
Choice B rationale
Naloxone. Naloxone is not the correct choice in this scenario. Naloxone is an opioid antagonist and is used to reverse the effects of opioids in cases of opioid overdose. Since the client is receiving magnesium sulfate, which is not an opioid, naloxone would not be effective in reversing the respiratory depression caused by magnesium sulfate. Administering naloxone in this situation would not address the underlying cause and may not improve the client's condition.
Choice C rationale
Flumazenil. Flumazenil is not the correct choice in this situation. Flumazenil is a benzodiazepine antagonist and is used to reverse the effects of benzodiazepines in cases of benzodiazepine overdose. Since the client is not receiving benzodiazepines but rather magnesium sulfate, flumazenil would not be effective in treating the respiratory depression caused by magnesium sulfate. Using flumazenil in this context would not be appropriate and could potentially lead to adverse effects.
Choice D rationale
Protamine sulfate. Protamine sulfate is not the correct choice in this scenario. Protamine sulfate is an antidote for heparin overdose, not for magnesium sulfate toxicity. It works by neutralizing the effects of heparin and preventing further anticoagulation. Since the client's issue is respiratory depression caused by magnesium sulfate, administering protamine sulfate would not be helpful and would not address the primary problem.
Correct Answer is ["A","B","F"]
Explanation
Choice A rationale:
The nurse should report visual disturbances to the provider. Visual disturbances in a pregnant client could indicate potential complications such as preeclampsia or eclampsia. These conditions are characterized by high blood pressure and can be harmful to both the mother and the fetus. Reporting visual disturbances promptly allows the provider to assess the situation and take appropriate actions to ensure the safety of the client and the baby.
Choice B rationale:
The nurse should also report blood pressure changes to the provider. The client's blood pressure has increased significantly from 179/99 mm Hg to 170/101 mm Hg over a short period. High blood pressure during pregnancy can be indicative of preeclampsia, a serious condition that requires close monitoring and management to prevent complications. Reporting the blood pressure changes promptly allows the provider to evaluate the situation and intervene as needed to safeguard the client's well-being.
Choice F rationale:
The nurse should report the fetal heart rate to the provider. Monitoring the fetal heart rate is crucial in prenatal care as it helps assess the well-being of the baby. Any abnormality in the fetal heart rate could indicate fetal distress or other complications. Promptly reporting any concerning changes in the fetal heart rate enables the provider to take appropriate measures to ensure the health and safety of the baby. The other choices (C, D, and E) are not the most critical findings in this scenario. While respiratory rate (C), deep tendon reflexes (D), and weight (E) are important aspects to monitor during pregnancy, they do not raise immediate concerns for potential complications like visual disturbances, blood pressure changes, and fetal heart rate abnormalities mentioned above. Nonetheless, they should still be documented and monitored regularly as part of routine prenatal care.
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