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.

Answer and Explanation

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.

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

Explanation

Choice A rationale

Diphtheria-acellular pertussis (Tdap) vaccine is recommended for pregnant clients during the third trimester, specifically between 27 and 36 weeks of gestation. This timing optimizes the transfer of maternal antibodies to the fetus, providing passive immunity against pertussis (whooping cough) in the newborn during their vulnerable early months, before they are old enough to receive their own vaccinations.

Choice B rationale

Inactivated influenza vaccine is highly recommended for pregnant clients during any trimester of pregnancy. Pregnancy alters the immune system, making pregnant individuals more susceptible to severe complications from influenza. Vaccination protects both the mother and, through passive antibody transfer, the newborn from influenza infection.

Choice C rationale

Varicella vaccine is a live attenuated vaccine and is contraindicated during pregnancy due to the theoretical risk of fetal infection. While the actual risk is very low, it is generally deferred until the postpartum period. Women of childbearing age should be screened for immunity and vaccinated if non-immune prior to conception or postpartum.

Choice D rationale

Measles, mumps, and rubella (MMR) vaccine is a live attenuated vaccine and is contraindicated during pregnancy due to the theoretical risk of fetal infection, particularly with rubella. Rubella infection during pregnancy can lead to congenital rubella syndrome, causing severe birth defects. Vaccination should occur before conception or postpartum.

Choice E rationale

Human papillomavirus (HPV) vaccine is not routinely recommended during pregnancy. While current data do not suggest harm, the vaccine has not been extensively studied in pregnant individuals. Vaccination should be completed before pregnancy or deferred until the postpartum period.

A. Place the newborn under a radiant heat source. B. Position the newborn in a supine position. C. Use sterile plastic wrap to cover the viscera. D. Apply petroleum gauze to the viscera.

Correct Answer is C

Explanation

Choice A rationale

While thermoregulation is critical for newborns, directly placing a newborn with an omphalocele under a radiant heat source without covering the exposed viscera first can lead to excessive fluid loss and potential hypothermia due to evaporation. The primary concern is protecting the exposed abdominal contents from injury and infection.

Choice B rationale

Positioning a newborn with an omphalocele in a supine position is generally appropriate, as it helps to keep the exposed viscera in a less compromised position. However, the most immediate and critical action is to protect the exposed organs from trauma, desiccation, and infection before considering positioning.

Choice C rationale

Using sterile plastic wrap to cover the viscera of a newborn with an omphalocele is a critical immediate nursing action. This creates a sterile barrier, prevents desiccation of the exposed abdominal contents, minimizes heat and fluid loss, and reduces the risk of infection, thus protecting the delicate organs until surgical repair.

Choice D rationale

Applying petroleum gauze to the exposed viscera is not the most appropriate or effective method for protecting an omphalocele. Petroleum gauze may stick to the delicate tissues, potentially causing trauma upon removal, and does not provide the same level of sterile barrier, moisture retention, or protection against environmental contaminants as sterile plastic wrap.

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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?

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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?