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).
Correct Answer : B,C,E
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
While oxygen may be indicated for fetal distress, the correct method is usually a non-rebreather mask at 10 L/min, not a venturi mask. A venturi mask delivers more precise oxygen concentrations but not high-flow oxygen, which is needed in this scenario.
Choice E: Perform a sterile vaginal examination (SVE)
A vaginal exam assesses labor progression, cervical dilation, station, and fetal position. This is important for determining whether labor is progressing appropriately or whether further interventions are needed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A.A client at 38 weeks of gestation with a cough and fever may have an infection, which is concerning, but it is not immediately life-threatening. The nurse should assess this client soon, but it is not the highest priority.
B.A client who has missed a period and reports vaginal spotting could be experiencing an early pregnancy complication, such as a miscarriage or ectopic pregnancy. This situation requires attention, but it is not as urgent as painless vaginal bleeding in the third trimester.
C.A client at 14 weeks of gestation with nausea and vomiting is likely experiencing common pregnancy symptoms. While these symptoms can be uncomfortable and require management, they are not typically urgent.
D.A client at 28 weeks of gestation with painless vaginal bleeding could be experiencing placenta previa or another serious condition that poses an immediate risk to both the mother and the fetus. This situation requires urgent assessment and intervention.
Correct Answer is C
Explanation
Choice A: While an upright position is generally beneficial during labor to improve uterine contractions and fetal positioning, it is not the priority in this situation of hypotension.
Choice B: Preparing for a cesarean birth is not indicated solely based on the blood pressure reading. Cesarean birth should be considered based on the overall assessment and clinical condition of the client and baby.
Choice C: The client's blood pressure reading of 82/52 mm Hg indicates hypotension. In this situation, the nurse should assist the client in turning onto her side to relieve pressure on the vena cava and improve blood flow to the placenta and the baby. Lying supine can compress the vena cava, leading to decreased venous return and reduced cardiac output, which may negatively affect fetal oxygenation and maternal wellbeing.
Choice D: Preparing for an immediate vaginal delivery is not the priority at this moment. The nurse should first address the hypotension and improve maternal blood flow before proceeding with delivery.
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