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

Exhibits

Based on the updated 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 exam

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":"B"},"E":{"answers":"A"},"F":{"answers":"None"},"G":{"answers":"B"}}

•   Increase the oxytocin infusion to 13 mU/min: This is an anticipated action. The client’s contractions are becoming more frequent and intense, and her cervix is dilating and effacing. Increasing the oxytocin infusion can help to further progress labor.
•   Place client in a side-lying position: This is an anticipated action. The side-lying position can help to improve maternal and fetal circulation and can also help to alleviate back pain.
•   Initiate bolus of primary IV fluids: This is an anticipated action. The client is in labor and may not be able to consume adequate fluids orally. Providing IV fluids can help to prevent dehydration.
•   Apply oxygen at 10 L/min via venturi mask: This is a nonessential action. The client’s respiratory rate and oxygen saturation are within normal limits, and she is not reporting any difficulty breathing.
•   Perform sterile vaginal exam: This is an anticipated action. Regular vaginal exams are necessary to assess the progress of labor, including changes in cervical dilation, effacement, and fetal station.
•   Assign a Bishop score: This is a nonessential action. The Bishop score is typically used to evaluate the readiness of the cervix for induction of labor. As the client is already in labor and her cervix is dilating and effacing, assigning a Bishop score is not necessary at this time.
•   Perform an amniotomy: This is a nonessential action. An amniotomy (artificial rupture of membranes) can be used to induce or augment labor, but it is not necessary if labor is progressing normally, as it appears to be in this client. Please note that these are potential actions and the healthcare provider should be informed immediately for further evaluation and management. It’s important to continue following the provider’s prescriptions and closely monitor the client’s condition.

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Correct Answer is C

Explanation

Choice A rationale
Assessing her skin for hydration and color can provide some information about the client’s overall health and nutritional status, but it doesn’t directly assess her diet.
Choice B rationale
Assessing a list she makes describing a good diet can provide information about the client’s knowledge of nutrition, but it doesn’t provide information about her actual dietary intake.
Choice C rationale
Asking her to describe her intake for the last week can provide a more accurate picture of her actual dietary habits and nutritional status.
Choice D rationale
Asking her to describe her total intake for a week during pregnancy can provide information about her dietary habits during pregnancy, but it doesn’t assess her current diet.

A. Observe the lochia during palpation of the fundus. B. Massage a firm fundus. C. Determine whether the fundus is midline. D. Document fundal height. E. Administer methylergonovine maleate.

Correct Answer is ["A","C","E"]

Explanation

Step 1: The nurse should observe the lochia during palpation of the fundus. This can help assess the amount and type of vaginal discharge after childbirth.
Step 2: The nurse should not massage a firm fundus. If the uterus is firm, it means it is contracting well to control bleeding.
Step 3: The nurse should determine whether the fundus is midline. A uterus that is not midline may indicate a full bladder, which can interfere with uterine contraction and lead to increased bleeding.
Step 4: Documenting fundal height is not typically done postpartum. Instead, the nurse assesses whether the fundus is firm and midline.
Step 5: The nurse should administer methylergonovine maleate if the uterus is boggy. This medication helps the uterus contract to control bleeding.

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A nurse is caring for a client who is 42 weeks of gestation. Exhibits Based on the updated 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.

Nursing Test Bank

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What is the role of a nurse in assessing a pregnant woman’s diet?

Correct Answer is C

Explanation

A nurse is caring for a client who had a vaginal delivery 2 hours ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

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

Exhibits

Based on the updated 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.