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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.

A.

Encourage frequent ambulation

B.

Ensure the client maintains a supine position while in bed

C.

Check FHR every 30 min

D.

Perform a Nitrazine test

E.

Prepare the client for catheterization

F.

Obtain CBC blood sample

G.

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"}}

  1. Encourage frequent ambulation - Anticipated
    • Ambulation can help progress labor and is generally encouraged if there are no contraindications.
  2. 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.
  3. Check FHR every 30 min - Anticipated
    • Regular monitoring of the fetal heart rate is essential to assess fetal well-being during labor.
  4. Perform a Nitrazine test - Anticipated
    • Since the client reports a gush of fluid, a Nitrazine test can help confirm whether the membranes have ruptured.
  5. Prepare the client for catheterization - Nonessential
    • The client has voided recently and doesn’t indicate difficulty, making catheterization unnecessary at this stage.
  6. 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.
  7. 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

✔

    

 


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Related Questions

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

The nurse should prepare to reinforce teaching with the client about a diabetic diet with a prescription of insulin therapy.

So, correct options are:

  1. A. diabetic diet
  2. A. insulin therapy
  3. Diabetic diet:
    1. The client has a history of gestational diabetes mellitus (GDM) during her previous pregnancy and is currently experiencing elevated blood glucose levels, as indicated by the oral glucose tolerance test and fasting glucose levels.
    2. A diabetic diet is essential to help manage blood glucose levels and prevent complications for both the mother and the baby.
  4. Insulin therapy:
    1. The client is already adhering to a diabetic diet and is taking insulin as prescribed, indicating that insulin therapy is part of her current management plan.
    2. Her glucose levels are still elevated despite dietary management, which means insulin therapy is necessary to maintain optimal glucose levels and reduce the risk of complications associated with GDM.

Correct Answer is C

Explanation

Choice A rationale

History of methicillin-resistant Staphylococcus aureus (MRSA) is not directly related to the use of a cervical cap. The main concern with a cervical cap is infection, but MRSA history alone doesn't make it a contraindication for this form of contraception.

Choice B rationale

History of thrombophlebitis is more of a concern with hormonal contraceptives due to the risk of blood clots. A cervical cap does not involve hormones, so this condition is not a direct contraindication.

Choice C rationale

History of toxic shock syndrome (TSS) is a contraindication for the use of a cervical cap because the cap can increase the risk of developing TSS again. TSS is associated with prolonged use of barrier contraceptives, which can create an environment that fosters the growth of bacteria responsible for TSS.

Choice D rationale

Type 1 diabetes mellitus is not a direct contraindication for the use of a cervical cap. The concern with diabetes is often related to blood glucose control and potential infections, but it doesn't specifically contraindicate the use of cervical caps.

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