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 C

Explanation

A. The deltoid muscle is not recommended for newborns; the vastus lateralis is the preferred site for intramuscular injections.
B. A 25-gauge needle is an appropriate size for newborn injections, but needle choice alone is not the priority action for this specific medication administration.
C. Phytonadione (Vitamin K) is typically administered within the first 6 to 12 hours after birth, allowing time for initial stabilization and bonding before injection, while still preventing vitamin K deficiency bleeding.
D. The mother’s Rh factor is unrelated to vitamin K administration; it is only assessed when considering the need for Rho(D) immune globulin.

A. History of methicillin-resistant Staphylococcus aureus B. History of thrombophlebitis C. Type 1 diabetes mellitus D. History of toxic shock syndrome

Correct Answer is D

Explanation

A. A history of methicillin-resistant Staphylococcus aureus (MRSA) does not contraindicate the use of a cervical cap. MRSA is an infection issue, but the cervical cap does not pose a significant risk for MRSA-related complications.
B. A history of thrombophlebitis is not a contraindication for the use of a cervical cap. Thrombophlebitis concerns are generally associated with hormonal contraceptives rather than barrier methods like cervical caps.
C. Type 1 diabetes mellitus is not a contraindication for using a cervical cap. Individuals with Type 1 diabetes can use barrier methods for contraception, though they should manage their condition carefully for overall health.
D. A history of toxic shock syndrome (TSS) is a contraindication for using a cervical cap. TSS is a severe, potentially life-threatening condition often associated with the use of barrier methods like tampons or cervical caps, which can increase the risk of infection.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer phytonadione to a newborn. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who inquires about a cervical cap for contraception. The nurse should identify that which of the following manifestations is a contraindication for the use of a cervical cap?

Correct Answer is D

Explanation

A nurse is collecting data from a newborn who was delivered at 40 weeks of gestation. Which of the following is an expected finding when eliciting reflexes from the newborn?

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A nurse is caring for a client who is at 41 weeks of gestation. The nurse should understand that which of the following findings can indicate a prenatal complication in this client?

A nurse in a provider's office is reviewing the medical record of a client who is requesting a diaphragm. Which of the following findings in the client's history should the nurse identify as a contraindication for this type of contraception?