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 D
Explanation
The correct answer is choice d. Vastus lateralis.
Choice A rationale:
The deltoid muscle is not typically used for newborn injections because it is too small and underdeveloped, making it an inappropriate site for intramuscular injections in this age group.
Choice B rationale:
The dorsogluteal muscle is also not recommended for newborns due to the risk of injury to the sciatic nerve and the muscle’s underdevelopment.
Choice C rationale:
The ventrogluteal muscle, while a good site for older children and adults, is not commonly used for newborns because it is not as easily accessible and developed as the vastus lateralis.
Choice D rationale:
The vastus lateralis muscle, located on the anterolateral aspect of the thigh, is the preferred site for intramuscular injections in newborns. It is well-developed and provides a large muscle mass, making it the safest and most effective site for administering vitamin K.
Correct Answer is B
Explanation
Choice A rationale:
If the client is Rh positive and the newborn is Rh negative, there is no indication for administering Rho(D) immune globulin. Rho(D) immune globulin is only given when the Rh-negative mother gives birth to an Rh-positive baby.
Choice B rationale:
This is the correct choice for administering Rho(D) immune globulin. When the mother is Rh negative and the newborn is Rh positive, there is a risk of Rh incompatibility. If the fetal blood enters the mother's circulation during delivery, her immune system may produce antibodies against Rh-positive blood cells, which can be harmful to future Rh-positive pregnancies. To prevent this, Rho(D) immune globulin is administered to the Rh-negative mother shortly after delivery.
Choice C rationale:
If both the mother and the newborn are Rh-negative, there is no risk of Rh incompatibility. Rho(D) immune globulin is not required in this situation.
Choice D rationale:
If both the mother and the newborn are Rh-positive, there is no risk of Rh incompatibility. Rho(D) immune globulin is not indicated in this case.
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