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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 A

Explanation

Choice A rationale

Amniocentesis is used to detect fetal genetic abnormalities, such as Down syndrome, by analyzing the amniotic fluid for genetic markers.

Choice B rationale

An empty bladder is required for the test only in late pregnancy to prevent bladder injury; however, in early pregnancy, a full bladder may be required to better visualize the uterus and amniotic fluid.

Choice C rationale

An x-ray is not typically used during the needle placement for amniocentesis. Ultrasound is the preferred method to guide the needle to avoid harm to the fetus and mother.

Choice D rationale

The test does not determine the volume of amniotic fluid; it is used primarily for genetic analysis, assessing fetal lung maturity, and diagnosing certain fetal infections.

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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