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A nurse in an antepartum unit is caring for a client.

Exhibits
Which of the following actions should the nurse take? Select all that apply.

Administer oxygen at 10L/min via nonrebreather face mask.

Request a prescription for hydralazine.

Initiate a bolus of IV fluid.

Assist the client to the left lateral position.

Request a prescription for oxytocin.

Notify the provider of the client's condition.

Prepare to administer an amnioinfusion.

Answer and Explanation

Correct Answer : A,C,D,F,G

A. Administer oxygen at 10 L/min via nonrebreather face mask. The fetal heart rate (FHR) is 168/min with minimal variability, which indicates potential fetal distress or hypoxia. Providing oxygen can improve fetal oxygenation.

B. Request a prescription for hydralazine. Hydralazine is used for severe hypertension in pregnancy (BP ≥160/110 mm Hg). The client’s BP is 132/84 mm Hg, which does not indicate a need for antihypertensive medication at this time.

C. Initiate a bolus of IV fluid. IV fluid bolus can improve placental perfusion, increase maternal blood pressure (if hypotension is a concern), and correct fetal heart rate abnormalities. This is especially important with minimal variability.

D. Assist the client to the left lateral position. Repositioning to the left lateral position improves uteroplacental blood flow and may help correct FHR abnormalities.

E. Request a prescription for oxytocin. Oxytocin is used to augment labor. However, the priority here is managing fetal distress, not increasing contractions. Oxytocin may worsen fetal distress, so it is not appropriate at this time.

F. Notify the provider of the client's condition. The combination of tachycardia (FHR 168/min), minimal variability, and meconium-stained fluid indicates possible fetal distress. The provider must be notified immediately to determine further interventions.

G. Prepare to administer an amnioinfusion. Meconium-stained fluid increases the risk of meconium aspiration syndrome. An amnioinfusion (infusion of sterile fluid into the amniotic sac via an intrauterine catheter) can help dilute thick meconium and improve fetal well-being.

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Correct Answer is A

Explanation

A. Reminding the AP about confidentiality is the appropriate immediate response. The nurse should provide education and reinforce HIPAA regulations to prevent future breaches.
B. Notifying the client is unnecessary and could cause undue distress. The priority is to address the behavior and prevent further violations.
C. Notifying the ethics committee is excessive for a first-time or minor violation. This step may be necessary if breaches continue despite education.
D. Filing an incident report is not required unless the breach has significant consequences. The best first step is direct education.

A. Blood pressure B. Fetal heart rate C. Fetal station D. Characteristics of amniotic fluid E. Duration of contraction

Correct Answer is ["B","D"]

Explanation

A. Blood pressure: The client’s BP is 128/84 mm Hg, which is within the normal range. Although the client has chronic hypertension, this BP reading does not indicate an immediate concern.

B. Fetal heart rate: The fetal heart rate (FHR) is 165/min, which is tachycardia (normal FHR range is 110–160/min). Fetal tachycardia can indicate infection, maternal fever, fetal distress, or hypoxia and requires immediate follow-up.

C. Fetal station: The station is 0, which means the presenting part is at the level of the ischial spines. This is normal for a laboring client at 4 cm dilation and does not require immediate intervention.

D. Characteristics of amniotic fluid: The fluid is green, indicating the presence of meconium-stained amniotic fluid, which suggests fetal distress or hypoxia. This requires immediate follow-up, as the baby is at risk for meconium aspiration syndrome.

E. Duration of contraction: The contraction lasted 40 seconds, which is within the normal range (30–90 seconds). This is not an immediate concern.

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A nurse in an antepartum unit is caring for a client. Exhibits Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse observes two assistive personnel (AP) discussing a client's information in the facility cafeteria. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse in an antepartum unit is caring for a client. Exhibits Select the 2 findings that require immediate follow-up.

Correct Answer is ["B","D"]

Explanation

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A nurse in an antepartum unit is caring for a client. Exhibits Which of the following actions should the nurse take? Select all that apply.

A nurse in an antepartum unit is caring for a client.

Exhibits
Which of the following actions should the nurse take? Select all that apply.