A nurse is caring for a client who has prolonged labor and is at risk for infection.

Which of the following actions should the nurse take to reduce this risk? (Select all that apply.)

Perform frequent vaginal exams.

Change perineal pads every 2 hours.

Encourage oral fluid intake.

Administer IV antibiotics as prescribed.

Use sterile gloves when providing perineal care.

Answer and Explanation

Correct Answer : B,C,D,E

These actions can help reduce the risk of infection for the client who has prolonged labor.

• Choice B is correct because changing perineal pads every 2 hours can prevent bacterial growth and contamination of the genital tract.

• Choice C is correct because encouraging oral fluid intake can help maintain hydration and blood volume, which can improve uterine perfusion and prevent maternal and fetal acidosis.

• Choice D is correct because administering IV antibiotics as prescribed can prevent or treat maternal peripartum infections, which are among the leading causes of maternal mortality worldwide.

• Choice E is correct because using sterile gloves when providing perineal care can prevent introducing pathogens into the genital tract.

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Correct Answer is D

Explanation

All of the above factors should be considered when discussing the possibility of vaginal birth after cesarean (VBAC).

Here’s why:

• The type of uterine incision used in the previous cesarean delivery affects the risk of uterine rupture during VBAC.A low transverse incision is associated with the lowest risk, while a high vertical incision is associated with the highest risk.

• The gestational age of the current pregnancy affects the success rate of VBAC.The optimal time for VBAC is between 39 and 40 weeks of gestation.Attempting VBAC before 37 weeks or after 41 weeks may increase the risk of complications.

• The presentation and position of the fetus affects the feasibility and safety of VBAC.A breech presentation, a transverse lie, or a posterior position may make vaginal delivery difficult or impossible.A cephalic presentation and an anterior position are more favorable for VBAC.

A. Gestational diabetes mellitus B. Polyhydramnios C. Macrosomic fetus D. Breech presentation.

Correct Answer is C

Explanation

A macrosomic fetus is a fetus that is larger than average, usually weighing more than 4 kg or 8.8 lb at birth.A large fetus can cause cephalopelvic disproportion (CPD), which is a condition where the baby’s head does not fit through the mother’s pelvis during labor.CPD can lead to prolonged or obstructed labor, which can endanger both the mother and the baby.

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A nurse is caring for a client who has prolonged labor and is at risk for infection. Which of the following actions should the nurse take to reduce this risk? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is counseling a client who has a small pelvis and wants to have a vaginal delivery. Which of the following factors should the nurse consider when discussing the possibility of vaginal birth after cesarean (VBAC)?

Correct Answer is D

Explanation

A nurse is reviewing the medical record of a client who is in labor and has cephalopelvic disproportion (CPD). Which of the following findings should the nurse expect to see in the record?

Correct Answer is C

Explanation

A nurse is reviewing the risk factors for uterine rupture with a group of nursing students. Which of the following risk factors should the nurse include? (Select all that apply.)

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A nurse is caring for a client who has prolonged and obstructed labor and develops a vesicovaginal fistula. Which of the following interventions should the nurse include in the plan of care?

A nurse is caring for a client who has prolonged labor and is at risk for infection.

Which of the following actions should the nurse take to reduce this risk? (Select all that apply.)