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.

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Correct Answer is D

Explanation

A. A glucose level of 60 mg/dL is within the normal range for a full-term newborn. Newborns generally have blood glucose levels between 40 and 60 mg/dL in the first few hours of life, and 60 mg/dL is considered acceptable for a 1-day-old newborn.
B. A WBC count of 10,000/mm³ is within the normal range for a newborn. Newborns can have elevated WBC counts due to the stress of birth, and this finding is not immediately concerning.
C. A platelet count of 225,000/mm³ is normal for a full-term newborn. Platelet counts in newborns generally range from 150,000 to 300,000/mm³, so this result falls within the expected range.
D. A hemoglobin level of 9.5 g/dL is low for a 1-day-old newborn. Normal hemoglobin levels for newborns are typically between 14 and 24 g/dL. Low hemoglobin may indicate anemia, which requires further evaluation and management.

A. "Place your baby in the bassinet in your room by the bed when you use the bathroom." B. "Carry your baby in your arms when you go for a walk in the hallway." C. "Make sure anyone caring for or transporting your baby is wearing an identification badge." D. "If your baby's identification band slips off, place it in the drawer of the bassinet."

Correct Answer is C

Explanation

A. Placing the baby in the bassinet by the bed when using the bathroom does not ensure the baby’s safety. It is important to use the bassinet only as a safe place for the baby, and the baby should not be left unattended or in potentially unsecured areas.
B. Carrying the baby in your arms while walking in the hallway does not prevent abduction and can be risky if you are not vigilant. It is safer to use secure methods for ensuring the baby's safety while moving through the hospital.
C. Ensuring that anyone caring for or transporting your baby is wearing an identification badge is a crucial safety measure. Identification badges help verify that only authorized personnel handle the baby, which helps prevent abductions.
D. If the baby’s identification band slips off, it should be reported immediately to hospital staff rather than being placed in a drawer. The identification band is essential for tracking and ensuring the baby’s safety, so it must be addressed properly to prevent confusion or security issues.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a full-term newborn who is 1 day old. Which of the following laboratory findings should the nurse report to the provider?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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