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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale :
Vitamin K decreases the newborn's risk of jaundice. Rationale: This statement is incorrect. Vitamin K plays no direct role in reducing the risk of jaundice in newborns. Jaundice is primarily caused by the accumulation of bilirubin in the blood, which is a different issue than hemorrhagic disorders.
Choice B rationale
Vitamin K decreases the newborn's risk of healthcare-associated infections. Rationale: This statement is incorrect. Vitamin K is not related to reducing the risk of healthcare-associated infections. Its main function is related to blood clotting and preventing hemorrhagic disorders.
Choice C rationale
Vitamin K decreases the newborn's risk of hemorrhagic disorders. Rationale: This statement is correct. Vitamin K is essential for the production of clotting factors in the blood, which helps prevent bleeding or hemorrhagic disorders in newborns. Newborns are born with low levels of vitamin K, so administering a vitamin K injection at birth is a common practice to prevent potential bleeding issues.
Choice D rationale
Vitamin K decreases the newborn's risk of complications from the Hepatitis B vaccine. Rationale: This statement is incorrect. Vitamin K is not directly related to reducing the risk of complications from the Hepatitis B vaccine. The vaccine is designed to protect against Hepatitis B infection, and vitamin K is not involved in its efficacy or safety.
Correct Answer is D
Explanation
Choice A rationale:
Helping the client to the bathroom to empty her bladder is not the appropriate response in this situation. The client's sudden urge to push indicates that she is in the second stage of labor, which is the pushing phase. The cervix is already dilated at 7 cm, and the fetus is at 1+ station, indicating that delivery is imminent. Emptying the bladder at this point is not a priority and may delay necessary actions.
Choice B rationale:
Assisting the client into a comfortable position is also not the appropriate response. The client's urge to push suggests that she is in the active stage of labor, and her cervix is already 7 cm dilated. Encouraging a comfortable position might not be suitable since the focus should be on monitoring the progress of labor and preparing for delivery.
Choice C rationale:
Having the client pant during the next few contractions is not the correct response either. Panting is typically recommended during the transition phase of labor to prevent rapid pushing and potential damage to the perineum. However, in this scenario, the client is already fully dilated, and the fetus is at 1+ station, indicating that the second stage of labor has commenced. Panting is not necessary at this point.
Choice D rationale:
The appropriate nursing response is to assess the perineum for signs of crowning. The sudden urge to push indicates that the baby is descending through the birth canal and may be close to crowning, which is when the baby's head becomes visible at the vaginal opening. By assessing for crowning, the nurse can determine if delivery is imminent and notify the healthcare provider for further actions and preparation for the baby's birth.
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