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A nurse on an antepartum unit is caring for a 32-year-old female client at 28 weeks gestation.

Exhibits

For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client. There must be at least one selection in every row. There does not need to be a selection in every column.

A.

Administration of IV fluids

B.

Continuous monitoring of FHR

C.

Abdominal ultrasound

D.

Digital cervical exam to assess dilation and effacement

E.

Laboratory testing: CBC, Blood Type & Rh, Coagulation Studies

F.

Placement of an internal fetal spiral electrode

G.

Administration of betamethasone

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}

  1. Administration of IV fluids: This is anticipated as it ensures the client remains well-hydrated, which is important for both maternal and fetal health.
  2. Continuous monitoring of FHR: This is anticipated to monitor the fetal well-being and ensure there are no signs of fetal distress.
  3. Abdominal ultrasound: This is anticipated to assess fetal growth, amniotic fluid levels, and placental positioning.
  4. Digital cervical exam to assess dilation and effacement: This is contraindicated because frequent cervical exams can increase the risk of infection and may cause unnecessary discomfort, especially if there are no signs of labor.
  5. Laboratory testing: CBC, Blood Type & Rh, Coagulation Studies: These tests are anticipated to provide important information about the client's blood count, blood type, Rh status, and coagulation parameters, which are crucial for managing potential complications.
  6. Placement of an internal fetal spiral electrode: This is contraindicated as it is an invasive procedure that carries risks, and it is unnecessary given that the FHR is within normal limits with external monitoring.
  7. Administration of betamethasone: This is anticipated as betamethasone is often given to promote fetal lung maturity in cases where there is a risk of preterm birth.


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Related Questions

Correct Answer is C

Explanation

Choice A rationale

Giving glucose water after feedings is not recommended for newborns undergoing phototherapy. Breastfeeding or formula feeding should be continued to provide adequate nutrition and hydration.

Choice B rationale

Instructing the client to avoid breastfeeding during treatment is not necessary. Breastfeeding should continue to promote bonding, provide nutrition, and help with the infant's hydration and bilirubin excretion.

Choice C rationale

Monitoring intake and output is crucial for a newborn receiving phototherapy to ensure proper hydration and assess the effectiveness of the treatment in lowering bilirubin levels.

Choice D rationale

Applying lotions and ointments throughout the treatment is not recommended, as they can interfere with the effectiveness of phototherapy. The skin should be clean and dry to maximize exposure to the phototherapy light.

Correct Answer is C

Explanation

Choice A rationale

Patterned breathing techniques can help in managing pain by focusing on controlled breathing, reducing anxiety, and providing a distraction from the pain, but are not specifically targeting back labor pains.

Choice B rationale

Effleurage involves light circular strokes on the abdomen and can help in managing general labor pain, but may not be as effective specifically for back labor pains.

Choice C rationale

Sacral counterpressure involves applying steady pressure to the sacral area, which can help relieve pain caused by back labor by counteracting the discomfort experienced in this area.

Choice D rationale

Guided imagery involves using mental visualization to distract from pain and promote relaxation, but may not be as effective in relieving the specific pain associated with back labor.

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