A nurse is admitting a female client, age 34, who is at 38 weeks of gestation to the labor and delivery unit for induction of labor.
Which of the following actions should the nurse take prior to implementing the provider’s prescriptions?
Ensure calcium gluconate is readily available.
Obtain the client’s heart rate.
Evaluate the client’s platelet count.
Determine if the client has aspirin sensitivity.
Review the client’s history for documentation of heart disease.
Correct Answer : A,B,D,E
Choice A rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity, often used in labor inductions complicated by preeclampsia or gestational hypertension. Having it readily available ensures prompt treatment of symptoms like respiratory depression or cardiac arrhythmias caused by magnesium overdose. This safety measure is critical because oxytocin use can increase uterine contractions and magnesium sulfate use requires close monitoring to prevent toxicity.
Choice B rationale: Obtaining the client’s heart rate prior to initiating oxytocin is essential to establish a baseline and monitor for tachycardia or bradycardia, which may affect maternal and fetal safety. Oxytocin can cause cardiovascular changes, including hypertension or arrhythmias, especially in clients with gestational hypertension. Continuous maternal cardiac assessment helps detect adverse effects early and adjust treatment accordingly.
Choice C rationale: Evaluating platelet count before induction is important in clients with gestational hypertension due to the risk of HELLP syndrome, which involves thrombocytopenia. Normal platelet levels range from 150,000 to 400,000/mm³; low levels increase bleeding risk during labor and delivery. Knowing platelet status guides safe management decisions, including anesthesia options and readiness for potential hemorrhagic complications.
Choice D rationale: Assessing for aspirin sensitivity is crucial because aspirin is often used in pregnancy for preeclampsia prevention. Aspirin hypersensitivity can lead to allergic reactions or exacerbation of asthma. Since the client has gestational hypertension, determining aspirin tolerance before administering medications is necessary to prevent adverse drug reactions and ensure safe pharmacologic management.
Choice E rationale: Reviewing the client’s history for heart disease documentation is vital as gestational hypertension increases cardiovascular risk. Preexisting heart conditions can complicate labor induction and oxytocin administration due to possible cardiac overload or arrhythmias. A comprehensive cardiac history ensures appropriate monitoring and interventions to prevent maternal and fetal complications during labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Immediate cesarean birth is generally not indicated for intrauterine fetal demise unless there are maternal complications, such as hemorrhage or infection, or if the client has a prior uterine scar that contraindicates vaginal birth. Cesarean section carries higher risks for the mother compared to vaginal delivery and is usually reserved for specific obstetrical indications.
Choice B rationale
Methotrexate is an antimetabolite medication primarily used in the management of ectopic pregnancy or gestational trophoblastic disease due to its cytotoxic effects on rapidly dividing cells. It is not indicated for the induction of labor or expulsion of a fetus in cases of intrauterine fetal demise as it does not stimulate uterine contractions effectively for this purpose.
Choice C rationale
In cases of intrauterine fetal demise at 36 weeks of gestation, scheduled induction of labor is the most common and generally recommended treatment option. This approach allows for planned delivery, reduces the psychological burden of carrying a deceased fetus, and minimizes the risk of complications such as coagulopathy for the mother, typically occurring after prolonged retention.
Choice D rationale
Dilation with suction curettage is a procedure typically used for early pregnancy termination or management of miscarriage in the first or early second trimester. At 36 weeks of gestation, the size of the fetus and uterus makes this procedure unsafe and inappropriate for delivery of a deceased fetus, posing significant risks of uterine perforation or hemorrhage.
Correct Answer is D
Explanation
Choice A rationale
Bladder distention upon palpation indicates urinary retention, not effective voiding. When the bladder remains distended, it signifies incomplete emptying, which can lead to urinary stasis and increased risk of urinary tract infections. Effective voiding requires coordinated detrusor muscle contraction and urethral sphincter relaxation, which is absent with distention.
Choice B rationale
A uterine fundus 2 cm above the umbilicus, especially in the postpartum period, suggests uterine atony and possible bladder distention. A full bladder can displace the uterus upward and to the side, preventing effective uterine contraction and involution, which is crucial for preventing postpartum hemorrhage. Normal fundal height should decrease daily.
Choice C rationale
Not feeling the urge to urinate could indicate nerve damage, overdistention with sensory nerve suppression, or a very low urine output. Normal bladder sensation is crucial for effective voiding. The absence of the urge may lead to prolonged bladder distention, increasing the risk of infection and bladder dysfunction, which hinders efficient emptying.
Choice D rationale
Urinating 30 mL/hr, while seemingly low, is a continuous output and suggests the client is able to empty their bladder, albeit slowly. Postpartum diuresis typically begins within 12 hours, with urine output of 100 to 250 mL/hr common. However, any consistent output, rather than retention, indicates some voiding effectiveness.
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