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? Click to specify whether the nurse's planned actions are anticipated, nonessential, or contraindicated
Increase the oxytocin infusion to 13 mu/min
Place client in a side lying position
Initiate bolus of primary IV fluids
Apply oxygen at 10 L/Min via venturi mask
Perform sterile vaginal examination (SVF)
Assign a bishop score
Perform an amniotomy
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"},"G":{"answers":"A"}}
Increase the oxytocin infusion to 13 mu/min:
Anticipated: This action is anticipated. Adjusting the oxytocin infusion rate may be appropriate based on the progress of labor and the response to the current infusion rate.
Place client in a side-lying position:
Anticipated: Placing the client in a side-lying position is an anticipated action. This position can enhance fetal oxygenation and blood flow, especially if there are concerns about fetal well-being.
Initiate a bolus of primary IV fluids:
Anticipated: Initiating a bolus of primary IV fluids is an anticipated action. Adequate hydration is important during labor, and a bolus may be initiated if there are signs of dehydration or as part of the overall management plan.
Apply oxygen at 10 L/Min via a venturi mask:
Anticipated: Applying oxygen at 10 L/min via a venturi mask is an anticipated action. Oxygen may be administered to the mother to improve oxygenation and, consequently, fetal oxygenation.
Perform sterile vaginal examination (SVE):
Contraindicated: There is no indication for a sterile vaginal examination (SVE) at this time based on the information provided. Frequent unnecessary SVEs can increase the risk of infection.
Assign a Bishop score:
Nonessential: Assigning a Bishop score is not essential at this point. The client's cervical status was assessed during admission, and the current focus is on monitoring the progress of labor with oxytocin.
Perform an amniotomy:
Anticipated: Depending on the clinical situation, performing an amniotomy (artificial rupture of membranes) may be anticipated as part of the labor induction process. However, the decision should be based on the overall assessment and progress of labor.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Variable decelerations are due to umbilical cord compression.
A. Variable decelerations are often associated with umbilical cord compression. This compression can occur when the umbilical cord is briefly compressed or squeezed, leading to transient decreases in fetal heart rate.
B. Variable decelerations are not typically a result of the administration of IV narcotic analgesics. They are more commonly associated with cord compression or other factors affecting fetal oxygenation.
C. Variable decelerations are not generally caused by uteroplacental insufficiency. Uteroplacental insufficiency is more commonly associated with late decelerations.
D. Variable decelerations are not primarily related to fetal head compression. While head compression can cause certain types of decelerations, variable decelerations are specifically associated with umbilical cord compression.
Correct Answer is B
Explanation
The correct answer is B.
A. Place warm, moist packs on the breasts: Warm, moist packs can increase blood flow and may actually stimulate milk production. This is not an appropriate intervention for lactation suppression.
B. Apply cabbage leaves to the breasts: This is the correct intervention. Cabbage leaves have been traditionally used to help reduce engorgement and suppress lactation. The mechanism is not fully understood, but it is believed that compounds in cabbage may help decrease milk supply.
C. Wear a loose-fitting bra: Wearing a loose-fitting bra can help reduce friction and discomfort, but it is not a specific intervention for lactation suppression.
D. Put green teabags on the breast: Green teabags are not commonly recommended for lactation suppression. Cabbage leaves are more widely accepted for this purpose.
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