A nurse is assisting with providing care for a 23-year-old female client who is in labor in the labor and delivery unit.

Exhibits

The nurse is assisting with planning care for the client. After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?

For each potential intervention, specify if the intervention is anticipated, nonessential, or contraindicated for the client.

Encourage frequent ambulation

Ensure the client maintains a supine position while in bed

Check FHR every 30 min

Perform a Nitrazine test

Prepare the client for catheterization

Obtain CBC blood sample

Check the client's temperature every hour

Answer and Explanation

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

Encourage frequent ambulation - Anticipated
- Ambulation can help progress labor and is generally encouraged if there are no contraindications.
Ensure the client maintains a supine position while in bed - Contraindicated
- Supine positioning can decrease uteroplacental blood flow and is generally not recommended during labor.
Check FHR every 30 min - Anticipated
- Regular monitoring of the fetal heart rate is essential to assess fetal well-being during labor.
Perform a Nitrazine test - Anticipated
- Since the client reports a gush of fluid, a Nitrazine test can help confirm whether the membranes have ruptured.
Prepare the client for catheterization - Nonessential
- The client has voided recently and doesn’t indicate difficulty, making catheterization unnecessary at this stage.
Obtain CBC blood sample - Anticipated
- A CBC can provide important information about the client's health status and identify any potential issues, like infection or anemia.
Check the client's temperature every hour - Anticipated
- Regularly monitoring temperature can help detect signs of infection, which is particularly important if the membranes have ruptured.

Intervention	Anticipated	Nonessential	Contraindicated
Encourage frequent ambulation	✔
Ensure the client maintains a supine position while in bed			✔
Check FHR every 30 min	✔
Perform a Nitrazine test	✔
Prepare the client for catheterization		✔
Obtain CBC blood sample	✔
Check the client's temperature every hour	✔

Nursing Test Bank

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Correct Answer is B

Explanation

Choice A rationale

Securing a clean diaper snugly across the newborn's penis might help manage minor bleeding but won't effectively address active oozing of bright red blood from a circumcision site.

Choice B rationale

Applying gentle pressure using a sterile dry gauze pad is the appropriate action to control bleeding. Applying direct pressure helps to stop the bleeding and allows for proper assessment of the wound.

Choice C rationale

Rinsing the newborn's penis with cool water might provide temporary relief but is not an effective method to control bleeding from a surgical site. It may also increase the risk of infection if not done sterilely.

Choice D rationale

Placing petroleum jelly on the bleeding site is typically done to prevent the diaper from sticking to the incision, but it is not sufficient to control active bleeding. .

A. Assist the client's partner to apply counterpressure to the sacrum. B. Maintain the client on bed rest until active labor begins. C. Insert an indwelling urinary catheter. D. Teach the client to hold their breath during contractions.

Correct Answer is A

Explanation

Choice A rationale

Assisting the client's partner to apply counterpressure to the sacrum can help alleviate the low-back pain associated with early labor by providing direct pressure to the area experiencing discomfort.

Choice B rationale

Maintaining the client on bed rest until active labor begins is not typically recommended, as mobility can help with the progression of labor and pain management.

Choice C rationale

Inserting an indwelling urinary catheter is not necessary for managing low-back pain in early labor and can increase the risk of infection and discomfort.

Choice D rationale

Teaching the client to hold their breath during contractions is not advisable, as it can lead to increased pain and decreased oxygenation for both the mother and baby. Breathing techniques are usually recommended to manage pain and ensure adequate oxygen delivery. .

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who had a circumcision 4 hr ago.During a diaper change, the nurse notes bright red blood oozing from the incision.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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