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 D

Explanation

Choice A rationale

Remaining in the sitz bath for only 10 minutes might not provide enough relief for a postpartum client with an episiotomy and hemorrhoids. Extended periods in a sitz bath can help reduce pain and promote healing.

Choice B rationale

Using numbing spray before cleansing is helpful for pain management, but it is not as beneficial as other methods for reducing inflammation and promoting healing.

Choice C rationale

Placing a heat pack to the area several times a day can help with pain but might not be as effective as other options in reducing swelling and promoting healing of hemorrhoids and episiotomy sites.

Choice D rationale

Applying witch hazel pads after urination helps reduce swelling, provides soothing relief, and promotes healing for both hemorrhoids and episiotomy sites. Witch hazel has natural astringent properties that are beneficial for postpartum perineal care.

A. The results can indicate a genetic disorder. B. This test determines how well my placenta is functioning. C. This test is done if there is a risk of an Rh incompatibility. D. The results will show if my baby's lungs are mature.

Correct Answer is D

Explanation

Choice A rationale

Lecithin/sphingomyelin (L/S) ratio does not indicate genetic disorders; it's used to assess fetal lung maturity.

Choice B rationale

The test does not determine placental function. It specifically evaluates fetal lung maturity through the ratio of lecithin to sphingomyelin in amniotic fluid.

Choice C rationale

The test is not used to assess the risk of Rh incompatibility. The L/S ratio focuses on lung development rather than blood compatibility issues.

Choice D rationale

The L/S ratio assesses the baby's lung maturity, indicating if the lungs produce enough surfactant for proper function after birth.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about perineal care to a client who is 2 hours postpartum and has an episiotomy and hemorrhoids.Which of the following statements by the client indicates understanding of the teaching?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who is undergoing amniotic fluid assessment for the lecithin/sphingomyelin ratio.Which of the following client statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

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