A nurse is assisting with providing care for a client who is in labor.

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, click to specify if the intervention is anticipated, nonessential, or contraindicated for the client.

Encourage frequent ambulation.

Prepare the client for catheterization

Ensure the client maintains a supine position while in bed.

Check FHR every 30 min.

Perform a Nitrazine test.

Check client's temperature every hour.

Obtain CBC blood sample

Answer and Explanation

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

- Encourage frequent ambulation: Anticipated. Ambulation can help progress labor, unless contraindicated by the healthcare provider.

- Prepare the client for catheterization: Non-essential. There is no current indication for catheterization as the client is voiding adequately and not in active labor.

- Ensure the client maintains a supine position while in bed: Contraindicated. The supine position can cause supine hypotensive syndrome in pregnant clients. A side-lying position is preferred to optimize blood flow.

- Check FHR every 30 min: Anticipated. Regular monitoring of FHR is important to assess fetal well-being during labor.

- Perform a Nitrazine test: Anticipated. Since the client reports fluid leakage, a Nitrazine test can help confirm if the membranes have ruptured.

- Check client's temperature every hour: Non-essential. The client's temperature is stable, and hourly checks are not indicated unless there are signs of infection or the membrane has been ruptured for an extended period.

- Obtain CBC blood sample: Anticipated. A CBC can help identify any underlying issues such as anemia or infection that could affect labor and delivery.

Nursing Test Bank

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Correct Answer is A

Explanation

A. The lecithin/sphingomyelin (L/S) ratio assesses fetal lung maturity. A higher ratio indicates that the baby's lungs are mature enough to handle breathing air outside the womb, which is the primary purpose of this test.
B. The L/S ratio test does not assess placental function. Placental function is evaluated through other tests, such as Doppler studies or biophysical profiles.
C. The L/S ratio test is not related to Rh incompatibility. Rh incompatibility issues are managed through different assessments, such as the Coombs test and Rh factor screening.
D. The L/S ratio test does not indicate genetic disorders. Genetic disorders are assessed through tests like amniocentesis or chorionic villus sampling, not the L/S ratio.

Correct Answer is []

Explanation

- Potential Condition: Placenta previa

- This condition is characterized by the placenta covering the cervix, which can lead to painless, bright red vaginal bleeding during the second or third trimester.

- Actions to Take:

1. Insert a large-bore peripheral IV catheter.

- This is a precautionary measure to ensure that there is immediate venous access for fluid and blood product administration if necessary.

2. Reinforce with the client to maintain bed rest.

- Limiting physical activity can help reduce the risk of further bleeding.

- Parameters to Monitor:

1. Vaginal bleeding

- Monitoring the amount, color, and frequency of bleeding is crucial to assess the ongoing blood loss and stability of the condition.

2. Fetal well-being

- Regular monitoring of fetal heart rate and movement is important to ensure the fetus is not in distress.

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Naxlex Comprehensive Predictor Exams

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 A

Explanation

Correct Answer is []

Explanation

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