A nurse is assisting with the admission of a client to the labor and delivery unit.
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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. Obtain a large-bore IV catheter. A large-bore IV catheter (18-gauge or larger) is necessary for blood transfusion to allow for rapid administration and reduce the risk of hemolysis. The provider has already prescribed this intervention.
B. Explain to the client that transfusion reactions are not serious. This statement is inaccurate and misleading. While many transfusion reactions are mild, some can be life-threatening, such as hemolytic reactions or anaphylaxis. The nurse should educate the client about signs and symptoms of a transfusion reaction and instruct them to report any discomfort or unusual sensations immediately.
C. Ensure two nurses confirm the information on the blood label. Before administering blood, two nurses must verify the blood product against the client's identification band, medical record, and blood bank documentation to prevent transfusion errors.
D. Ensure the transfusion tubing is flushed with dextrose 5% in water. Blood products should only be administered with normal saline (0.9% sodium chloride) because dextrose-containing solutions can cause red blood cell hemolysis. The nurse should ensure the IV tubing is primed with normal saline before starting the transfusion.
E. Witness the client signing consent for transfusion. Informed consent is required before administering a blood transfusion. While obtaining consent is the provider’s responsibility, the nurse can witness the signing and ensure that the client understands the procedure.
Correct Answer is A
Explanation
A. "I've been talking to the baby a lot and haven't told anyone except my mom yet." Talking to the baby suggests emotional attachment and early bonding, which indicates the adolescent is beginning to process and accept the pregnancy. Sharing the news with a trusted individual, like their mother, also suggests they are seeking support.
B. "I don't want to tell my partner in case they don't believe me." Avoiding disclosure due to fear of disbelief suggests uncertainty or anxiety about the pregnancy, which may indicate emotional unpreparedness. Open communication is important for coping and planning.
C. "I've decided to take a break from school and focus on the baby." While prioritizing the baby is important, making major life decisions without exploring available resources may reflect a reactive rather than a well-thought-out approach. Support systems can help balance education and parenting responsibilities.
D. "I don't need to worry about how much I eat now that I'm pregnant." This statement indicates a misunderstanding of nutritional needs during pregnancy. Proper nutrition is crucial for both maternal and fetal health, and disregarding dietary needs may suggest a lack of readiness for the responsibility of pregnancy.
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