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 ["B","C","E","F"]

Explanation

A. Hemoglobin: Although an improvement in hemoglobin would be ideal, it may take more time to see a significant change after blood loss or transfusion. A rise in hemoglobin indicates that the body is recovering from blood loss, but it is not as immediate an indicator of improvement as other factors, such as heart rate or blood pressure stabilization.

B. Heart rate: A decrease in the heart rate toward the normal range (60-100 beats/min) indicates improvement in the client's condition. The initial heart rate of 120-128 beats/min (tachycardia) suggests the client may have been compensating for blood loss or pain. A more stable heart rate would suggest a response to treatment and improvement in their cardiovascular status.

C. Pain level: A reduction in pain score is an important indicator of recovery post-surgery. After an emergency cesarean birth, pain management is a critical aspect of recovery, and a reduction in pain intensity would suggest that the client is improving and responding well to pain management interventions.

D. Temperature: A normal temperature would suggest no infection or complications. However, temperature changes in the immediate postpartum period can be influenced by various factors (e.g., infection, hormonal changes, or recovery from surgery). It is not as immediate an indicator of recovery as heart rate or blood pressure.

E. Vaginal bleeding: A decrease in vaginal bleeding, especially after a cesarean, would indicate that bleeding is being effectively controlled and the uterus is contracting appropriately, reducing the risk of hemorrhage or complications like uterine atony.

F. Blood pressure: A return to normal blood pressure levels (e.g., closer to the pre-pregnancy baseline) would indicate that the client's circulatory status is stabilizing. The dropping blood pressure seen earlier (from 95/62 mm Hg to 85/48 mm Hg) indicated hypovolemic shock or a response to blood loss, so stabilization and an increase in blood pressure would be a positive sign.

A. COPD B. Hypertension C. Dermatitis D. Smoking history E. Type 2 diabetes mellitus F. Hypothyroidism

Correct Answer is ["A","D","E"]

Explanation

A. COPD: Clients with chronic obstructive pulmonary disease (COPD) are at increased risk for pneumonia due to compromised lung function, chronic inflammation, and decreased mucociliary clearance, making it easier for pathogens to infect the lungs.

B. Hypertension: While hypertension is a significant cardiovascular risk factor, it does not directly increase the risk of pneumonia. Therefore, it is not a relevant factor in this case.

C. Dermatitis: Dermatitis is a skin condition and does not affect lung function or immunity in a way that would increase the risk of pneumonia.

D. Smoking history: Smoking damages the respiratory epithelium and impairs the immune defenses of the lungs, making smokers more susceptible to respiratory infections such as pneumonia.

E. Type 2 diabetes mellitus: Diabetes compromises immune function and increases the risk of infections, including pneumonia, due to hyperglycemia impairing neutrophil function and other immune responses.

F. Hypothyroidism: While hypothyroidism may cause some general symptoms such as fatigue, it does not directly compromise respiratory function or immunity in a way that increases the risk of pneumonia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits The nurse is caring for a client on the postpartum unit. The nurse is caring for the client following an emergency cesarean birth. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

Correct Answer is ["B","C","E","F"]

Explanation

A nurse working in the emergency department (ED) is admitting a client. Exhibits The nurse is reviewing the client's medical record. Which of the following conditions should the nurse identify as a risk factor for pneumonia? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

A nurse is caring for a neonate in the neonatal intensive care unit. Exhibits Complete the following sentence by using the lists of options. The neonate is most at risk for _____ due to ______

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A nurse is assessing the coping strategies of a client who has recently retired. Which of the following statements by the client indicates that the client is using compensation as a defense mechanism?

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