A nurse is caring for a client.

Exhibits

A nurse is continuing care for the client.

For each potential nursing action, click to specify if the nursing action 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.

Obtain consent for cesarean birth

Provide intermittent fetal heart rate monitoring

Administer oxygen 10 L via face mask

Prepare the client for an amnioinfusion

Initiate IV bolus lactated Ringer’s

Insert a urinary catheter

Answer and Explanation

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

Nursing action	Anticipated	Contraindicated
Obtain consent for cesarean birth	✅
Provide intermittent fetal heart rate monitoring	✅
Administer oxygen 10 L via face mask	✅
Prepare the client for an amnioinfusion		✅
Initiate IV bolus lactated Ringer’s	✅
Insert a urinary catheter		✅

Rationale:

Obtain consent for cesarean birth: This is anticipated because the client is presenting with uterine contractions, vaginal bleeding, and abdominal pain, which may indicate complications such as placental abruption or abnormal placental attachment, potentially requiring a cesarean birth for the safety of both the mother and fetus.

Provide intermittent fetal heart rate monitoring: This is anticipated as it is essential to monitor fetal well-being, especially with the reported minimal fetal heart rate variability and potential for fetal distress.

Administer oxygen 10 L via face mask: This is anticipated to improve oxygenation, especially if there is a risk of fetal distress or compromised perfusion due to maternal blood loss.

Prepare the client for an amnioinfusion: This is contraindicated in the setting of vaginal bleeding and suspected placental abruption, as amnioinfusion is typically used for conditions such as oligohydramnios, and it could increase the risk of additional complications in this case.

Initiate IV bolus lactated Ringer’s: This is anticipated as the client has signs of hypovolemic shock due to blood loss, and an IV bolus would be necessary to improve fluid volume and blood pressure.

Insert a urinary catheter: This is contraindicated unless clinically necessary, as urinary catheterization may not be indicated in the immediate management of placental issues or bleeding complications without further evaluation, and it could introduce an infection risk.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Place a warm, moist compress on the site: This helps reduce the inflammation associated with phlebitis by promoting blood flow to the affected area and easing discomfort.

B. Insert a new IV catheter distal to the discontinued IV site: Incorrect. The site with phlebitis should not be used for a new IV insertion. A new, unaffected site should be chosen.

C. Apply a pressure dressing at the IV site: Incorrect. A pressure dressing is not required for phlebitis unless there is active bleeding.

D. Express drainage from the IV site and send it to be cultured: Incorrect. Expressing drainage is not a standard practice for phlebitis unless there is an indication of infection and purulent drainage.

A. Discuss methods of how to communicate with the client about resolving problem behaviors. B. Suggest that the caregiver seek a prescription for an antipsychotic medication for the client. C. Assist the caregiver to arrange for a daycare program for the client. D. Recommend allowing the client to have time alone in their room throughout the day.

Correct Answer is C

Explanation

A. Communication strategies may help but won’t directly reduce caregiver stress.

B. Antipsychotic medication is not a first-line solution and should be prescribed only for specific symptoms.

C. Arranging a daycare program provides respite for the caregiver and promotes social interaction for the client.

D. Allowing the client to be alone may increase anxiety and is unsafe.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at a peripheral IV site. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver states, "Providing constant care is very stressful and is affecting all areas of my life." Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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