Exhibits

The nurse is assessing the client 24 hr later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.

Choice A rationale: Verifying that the client has signed an informed consent form is essential before initiating cervical ripening with prostaglandins. Dinoprostone insertion is an invasive procedure with potential risks such as uterine tachysystole, fetal distress, or the need for cesarean delivery. Informed consent ensures that the client understands the risks, benefits, and alternatives, and it fulfills both ethical and legal requirements. Therefore, this intervention must be included in the plan of care prior to medication administration.

Choice B rationale: Terbutaline, a beta-adrenergic agonist, must be readily available because prostaglandins can cause uterine tachysystole or hyperstimulation, which compromises uteroplacental blood flow and fetal oxygenation. Terbutaline relaxes uterine smooth muscle, reversing hyperstimulation and preventing fetal hypoxia. Having this medication immediately accessible is a critical safety measure during induction. This aligns with the provider’s order to notify for tachysystole or nonreassuring FHR and ensures rapid intervention if complications arise.

Choice C rationale: Maintaining bed rest for 2 hours after prostaglandin administration is not recommended. The correct evidence-based practice is to keep the client in a side-lying or supine position with a wedge for 30 to 60 minutes to allow absorption of the medication and reduce the risk of expulsion. Prolonged bed rest beyond this period is unnecessary and increases the risk of venous thromboembolism. Therefore, this intervention is not appropriate for the plan of care.

Choice D rationale: Dinoprostone (Cervidil, Prepidil) is a prostaglandin E2 analog that requires refrigeration to maintain stability and potency. The medication should be kept refrigerated until just before administration to ensure effectiveness. Improper storage at room temperature for extended periods can degrade the drug, reducing its efficacy in cervical ripening. Therefore, refrigeration until administration is a correct nursing intervention and should be included in the plan of care.

Choice E rationale: Assisting with an amniotomy before prostaglandin placement is not appropriate. Prostaglandins are used to ripen the cervix before oxytocin induction, and amniotomy is typically performed later to augment labor once the cervix is favorable. Performing an amniotomy prematurely increases the risk of infection, cord prolapse, and fetal distress. Since the membranes are intact and the cervix is closed and thick, prostaglandin ripening is indicated first, not amniotomy.

Choice F rationale: Keeping calcium gluconate at the bedside is necessary when administering magnesium sulfate, not prostaglandins. Calcium gluconate is the antidote for magnesium toxicity, which causes respiratory depression and cardiac complications. Since this client is not receiving magnesium sulfate, calcium gluconate is not relevant to the current plan of care. Therefore, this intervention is not appropriate in this context.

Choice G rationale: Having the client void before insertion of the prostaglandin is correct. An empty bladder reduces the risk of bladder injury during insertion, improves maternal comfort, and prevents urinary retention while the client remains in the side-lying position for 30 to 60 minutes after administration. This intervention is specifically ordered by the provider and is a standard nursing action to optimize safety and comfort during cervical ripening.

Choice A rationale

Nausea is a very common, generally mild, and often transient side effect of oral contraceptives, usually caused by the estrogen component. It typically improves over a few cycles as the body adjusts to the hormonal changes and does not usually necessitate immediate notification of the healthcare provider.

Choice B rationale

Abdominal bloating is a frequent and minor adverse effect of hormonal contraception, often related to fluid retention or altered gastrointestinal motility due to hormonal fluctuation, which is usually self-limiting or manageable with minor adjustments, thus not requiring urgent reporting.

Choice C rationale

Breast tenderness or mastalgia is a common, dose-related side effect linked to hormonal stimulation (estrogen and/or progestin) of the mammary tissue, similar to premenstrual symptoms, and is generally considered a nuisance rather than an immediate danger sign.

Choice D rationale

Persistent headaches, especially if severe, unilateral, or associated with visual changes, can be a symptom of a serious adverse event like a cerebrovascular accident (stroke) or thrombotic events (e.g., cerebral venous thrombosis), which are rare but serious risks associated with hormonal contraceptives, necessitating immediate medical evaluation.