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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.

A.

Obtain consent for cesarean birth

B.

Provide intermittent fetal heart rate monitoring

C.

Administer oxygen 10 L via face mask

D.

Prepare the client for an amnioinfusion

E.

Initiate IV bolus lactated Ringer’s

F.

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.


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Related Questions

Correct Answer is C

Explanation

A. Exclude nutritional supplements from the list of medications the client reports: Incorrect. Nutritional supplements are medications and should be included in the medication reconciliation process.

B. Encourage the client to make his own list after he returns to his home: Incorrect. The nurse should be responsible for gathering the complete medication history upon admission, not relying on the client’s list from home.

C. Compare new prescriptions with the list of medications the client reports: This is the correct step in medication reconciliation. The nurse needs to ensure that new medications are compatible with the client's current medications and review any changes.

D. Include any adverse effects of the medications the client might develop: Incorrect. Adverse effects are not part of the medication reconciliation process; the focus is on identifying all current medications, including prescriptions, over-the-counter drugs, and supplements.

Correct Answer is A

Explanation

A. Privately interviewing the client is the first step in assessing the possibility of elder abuse and gathering detailed information.

B. Notifying risk management is necessary after abuse is confirmed or suspected, but it is not the first step.

C. Informing the transferring agency is not appropriate until further investigation.

D. Contacting the family may not be appropriate if they are suspected of abuse.

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