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A nurse is caring for a client who is 42 weeks of gestation. Based on the assessment findings, which of the following actions should the nurse plan to take? (Select all that apply.)

Increase the oxytocin infusion to 13 mu/min.

Initiate a bolus of primary IV fluids.

Place the client in a sidelying position.

Apply oxygen at 10 L/min via a venturi mask.

Perform a sterile vaginal examination (SVE).

Answer and Explanation

Correct Answer : B,C,D

The correct answer is B, C, and D.

Choice A: Increase the oxytocin infusion to 13 mu/min

Increasing the oxytocin infusion is not indicated in this scenario. Oxytocin is used to induce or augment labor, but if the fetal heart rate tracing is abnormal (Category 3), increasing oxytocin could exacerbate fetal distress. The priority is to stabilize the fetal condition before considering increasing oxytocin.

Choice B: Initiate a bolus of primary IV fluids

Initiating a bolus of primary IV fluids is appropriate. This action helps improve placental perfusion and maternal hydration, which can be beneficial in response to abnormal fetal heart rate tracings. Adequate hydration can enhance uteroplacental blood flow and improve fetal oxygenation.

Choice C: Place the client in a sidelying position

Placing the client in a sidelying position is recommended. This position can improve uteroplacental perfusion and fetal oxygenation, especially if there are signs of fetal distress. It helps to alleviate pressure on the inferior vena cava, enhancing blood flow to the placenta.

Choice D: Apply oxygen at 10 L/min via a venturi mask

Applying oxygen at 10 L/min via a venturi mask is indicated for improving fetal oxygenation in cases of abnormal fetal heart rate patterns. This intervention can help increase the oxygen available to the fetus, which is crucial in managing fetal distress.

Choice E: Perform a sterile vaginal examination (SVE)

Performing a sterile vaginal examination (SVE) is not indicated based on the provided assessment findings. While SVE is useful for assessing cervical dilation and labor progression, it is not a priority in this situation where the main concern is fetal well-being. Unnecessary SVEs can increase the risk of infection.

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Correct Answer is A

Explanation

Choice A: Kegel exercises are specifically designed to strengthen the pelvic floor muscles, which play a crucial role during childbirth. Strengthening these muscles can aid in better control during labor and delivery, facilitating stretching and reducing the risk of injury.

Choice B: Kegel exercises do not have a direct impact on preventing constipation during pregnancy. However, they may help improve bowel control and prevent fecal incontinence.

Choice C: While Kegel exercises can improve posture and core strength, their primary benefit lies in strengthening the pelvic muscles, not directly reducing backaches throughout pregnancy.

Choice D: Kegel exercises are not intended to prevent stretch marks on the abdomen. Stretch marks are caused by the stretching of the skin during pregnancy and are not related to pelvic muscle exercises.

A. All of the clients B. A client who has a history of preterm labor C. A client who has mitral valve prolapse D. A client who has been exposed to AIDS

Correct Answer is A

Explanation

A) All of the clients: Maternal serum alphafetoprotein (MSAFP) screening is a routine prenatal test offered to all pregnant women, usually between 15 and 20 weeks of gestation. It is used to screen for certain fetal anomalies, including neural tube defects such as spina bifida and anencephaly. Regardless of a client's medical history or risk factors, the MSAFP screening is typically recommended for all pregnant individuals as part of routine prenatal care.
B) A client who has a history of preterm labor: Preterm labor history is not a specific indication for MSAFP screening. This test is primarily used to screen for fetal anomalies, not preterm labor risk assessment.
C) A client who has mitral valve prolapse: Mitral valve prolapse is also not an indication for MSAFP screening. The test is focused on assessing fetal health and not maternal heart conditions.
D) A client who has been exposed to AIDS: MSAFP screening is not related to maternal exposure to AIDS. It is a test focused on assessing the fetus's risk of certain congenital abnormalities.

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A nurse is caring for a client who is 42 weeks of gestation. Based on the assessment findings, which of the following actions should the nurse plan to take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching?

Correct Answer is A

Explanation

A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate the provider will order a maternal serum alphafetoprotein (MSAFP) screening for which of the following clients?

Correct Answer is A

Explanation

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