A nurse is assisting with the admission of a client to the labor and delivery unit.

Exhibits

Which of the following actions should the nurse recommend including in the client's plan of care? For each potential recommendation, click to specify if the recommendation is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Administer oxygen at 10 L/min via non-rebreather face mask as needed.

Position the client in lateral side-lying position.

Administer magnesium sulfate IV.

Encourage the client to void every 2 hr.

Administer prophylactic IV antibiotic.

Evaluate the client for uterine tachysystole.

Answer and Explanation

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

Anticipated:

Administer oxygen at 10 L/min via non-rebreather face mask as needed: The client has late decelerations, indicating possible fetal hypoxia. Providing supplemental oxygen can enhance placental oxygenation and improve fetal status.
Position the client in lateral side-lying position: This position improves uteroplacental perfusion by relieving compression of the inferior vena cava, which can help resolve late decelerations and improve fetal oxygenation.
Encourage the client to void every 2 hr: A full bladder can impede fetal descent and contribute to labor discomfort. Regular voiding helps prevent bladder distention and promotes labor progress.
Administer prophylactic IV antibiotic: The client is positive for Group B streptococcus (GBS), which necessitates prophylactic antibiotic administration during labor to reduce the risk of neonatal infection.
Evaluate the client for uterine tachysystole: The client's contractions have increased in frequency and intensity. Assessing for excessive uterine activity is critical to prevent fetal distress and complications such as uterine rupture.

Contraindicated:

Administer magnesium sulfate IV: Magnesium sulfate is used for seizure prophylaxis in preeclampsia or for tocolysis in preterm labor. The client does not have preeclampsia, and labor is at term, making this intervention unnecessary.

Nursing Test Bank

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Correct Answer is B

Explanation

A. "Anticipate that the insulin glargine will peak in 3 hours." Insulin glargine is a long-acting basal insulin with no pronounced peak. Instead, it provides a steady level of insulin over 24 hours, reducing the risk of hypoglycemia. Unlike short- or intermediate-acting insulins, it does not have a defined peak time.
B. "Draw up the insulin lispro and insulin glargine in separate syringes." Insulin glargine should never be mixed with other insulins in the same syringe, as it has a unique pH that can cause precipitation when combined. Insulin lispro, a rapid-acting insulin, can be mixed with some other insulins, but it must be drawn up separately from insulin glargine to maintain its stability and effectiveness.
C. "Expect insulin glargine to be cloudy." Insulin glargine is a clear solution. Cloudy insulins, such as NPH (neutral protamine Hagedorn), require gentle rolling before administration to mix the suspension evenly. If insulin glargine appears cloudy, it may be contaminated or compromised and should not be used.
D. "Take an extra dose of insulin lispro prior to aerobic exercise." Taking extra insulin lispro before exercise can increase the risk of hypoglycemia, as physical activity naturally lowers blood glucose levels. Clients with diabetes should monitor their blood glucose before, during, and after exercise and may need to adjust their carbohydrate intake rather than taking additional insulin.

A. "I should not feed my baby anything for 2 hours prior to an immunization." B. "My baby will receive the rotavirus immunization orally." C. "I should expect my baby to have a high fever for 24 hours after an immunization." D. "My baby will receive three doses of the meningococcal immunization before kindergarten."

Correct Answer is B

Explanation

A. "I should not feed my baby anything for 2 hours prior to an immunization." There are no dietary restrictions before routine infant vaccinations. Feeding is encouraged as usual, and breastfeeding may help soothe the infant after immunization.
B. "My baby will receive the rotavirus immunization orally." The rotavirus vaccine is administered orally as a liquid, not as an injection. This vaccine helps protect against severe diarrheal illness caused by rotavirus.
C. "I should expect my baby to have a high fever for 24 hours after an immunization." Mild fever and irritability are common side effects, but a high fever is not expected. Persistent or severe fever should be reported to a healthcare provider.
D. "My baby will receive three doses of the meningococcal immunization before kindergarten." The meningococcal vaccine is not routinely given in infancy. It is typically administered at 11–12 years of age, with a booster at 16 years, unless the infant is at high risk due to certain medical conditions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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