A nurse is caring for a client who is 42 weeks of gestation.

Exhibits

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

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A Reason:

Bilirubin 9 mg/dL is correct. A bilirubin level of 9 mg/dL in a newborn, especially at 4 hours old, is elevated and needs prompt attention. High bilirubin levels in newborns can be indicative of jaundice, and severe jaundice may lead to complications such as kernicterus. Monitoring and managing bilirubin levels are crucial to prevent potential neurologic damage.

Choice B Reason:

Hemoglobin 15 g/dL is incorrect. This hemoglobin level is within the normal range for a newborn. It's important to note that newborns often have higher hemoglobin levels shortly after birth, and this value is consistent with normal physiological ranges.

Choice C Reason:

Platelets 175,000/mm³ is incorrect. A platelet count of 175,000/mm³ is within the normal range for a newborn. There is no immediate concern based on this platelet count.

Choice D Reason:

Hematocrit 45% is incorrect. A hematocrit level of 45% is within the normal range for a newborn. Like hemoglobin, hematocrit levels can be higher in newborns shortly after birth, and this value falls within the expected range.

A. Instruct the client to increase her respiratory rate to more than 42 breaths per min. B. Assist the client to breathe into a paper bag C. Have the client tuck her chin to her chest. D. Administer oxygen via nasal cannula

Correct Answer is C

Explanation

A. Instructing the client to increase her respiratory rate to more than 42 breaths per minute may exacerbate hyperventilation and cause respiratory alkalosis. This is not the appropriate action in this situation.

B. Breathing into a paper bag is an outdated and potentially dangerous practice. It can lead to a buildup of carbon dioxide in the body and may have adverse effects on both the mother and the baby. It is not recommended.

C. Having the client tuck her chin to her chest is the correct action.

This maneuver helps decrease the respiratory rate and prevent hyperventilation. It promotes a controlled and appropriate breathing pattern during labor.

D. Administering oxygen via nasal cannula is not the first-line intervention for lightheadedness and tingling during labor. The client's symptoms are likely due to hyperventilation, and addressing the breathing pattern is more appropriate.

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A nurse is caring for a client who is 42 weeks of gestation. Exhibits 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

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Explanation

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A nurse is caring for a client who is 42 weeks of gestation.

Exhibits

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