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. Open the dampers of fireplaces. Keeping fireplace dampers open would allow contaminated outdoor air to enter the home, increasing exposure to harmful chemicals. During an outdoor chemical disaster, it is essential to seal the home as much as possible to prevent infiltration of toxic substances.
B. Cover heat registers with plastic and tape. Sealing heat registers helps prevent outside air from circulating into the home through ventilation systems. This precaution reduces exposure to airborne chemicals by limiting pathways for contamination. Creating an airtight environment is a key strategy in shelter-in-place recommendations during chemical disasters.
C. Exit the home as quickly as possible. Evacuating during an outdoor chemical disaster may increase the risk of exposure if toxic fumes are present. Authorities typically advise sheltering in place with sealed windows and doors unless an evacuation order is issued. Leaving should only occur when officials confirm that it is safe.
D. Turn on ceiling fans and air conditioners. Running ventilation systems like fans and air conditioners can draw in outside air, increasing exposure to hazardous chemicals. Instead, all air systems should be turned off to minimize circulation of contaminated air within the home.

A. Administer oxygen to the client. B. Notify the charge nurse. C. Document client findings and interventions taken. D. Place the client in high Fowler's position.

Correct Answer is D,A,B,C

Explanation

D. Place the client in high Fowler’s position. Positioning the client upright maximizes lung expansion and improves oxygenation. This is the first step to alleviate respiratory distress before additional interventions.

A. Administer oxygen to the client. Once the client is positioned appropriately, providing supplemental oxygen helps increase oxygen saturation and relieve hypoxia. The nurse should titrate oxygen as needed according to facility protocols or provider orders.

B. Notify the charge nurse. After immediate interventions are in place, the nurse should inform the charge nurse to ensure further assessment and necessary medical interventions. The charge nurse may escalate care or contact the provider for additional management.

C. Document client findings and interventions taken. Once the client’s condition has been addressed and reported, documentation is necessary to record assessment findings, interventions provided, and the client's response. Accurate documentation ensures continuity of care and legal protection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with a community health presentation about home safety precautions when there is an outdoor chemical disaster nearby. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse enters a client's room and finds the client experiencing respiratory distress. Place the following interventions in the order in which the nurse should perform them. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is D,A,B,C

Explanation

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