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

The correct answer is choiceC. Respiratory rate.

Choice A rationale:

Monitoring the fetal heart rate (FHR) is crucial during labor to assess the well-being of the fetus.However, when administering magnesium sulfate, the primary concern is the mother’s respiratory status due to the risk of respiratory depression, which can be a side effect of the medication.

Choice B rationale:

While bowel sounds are an important part of a comprehensive assessment, they are not the primary concern when administering magnesium sulfate.Magnesium sulfate primarily affects the neuromuscular and respiratory systems.

Choice C rationale:

Respiratory rate is the primary nursing assessment for a client receiving magnesium sulfate IV.Magnesium sulfate can cause respiratory depression, so it is essential to monitor the client’s respiratory status closely to detect any signs of respiratory compromise early.

Choice D rationale:

Monitoring temperature is important in any clinical setting, but it is not the primary concern when administering magnesium sulfate.The primary focus should be on the respiratory rate due to the potential for respiratory depression.

A. To prevent basal metabolic rate reduction. B. To stimulate brown fat production. C. To maintain body temperature. D. To prevent hypothermia.

Correct Answer is C

Explanation

Choice A rationale
Placing a newborn under a radiant heat warmer after birth does not directly prevent basal metabolic rate reduction. The primary function of a radiant heat warmer is to maintain the newborn’s body temperature and prevent hypothermia.
Choice B rationale
While brown fat production is a mechanism used by newborns to generate heat, placing a newborn under a radiant heat warmer does not stimulate brown fat production.
Choice C rationale
The primary purpose of placing a newborn under a radiant heat warmer after birth is to maintain the newborn’s body temperature. Newborns can lose heat rapidly, as they have a

large surface area compared to their body weight. The radiant heat warmer provides a controlled environment that helps maintain the newborn’s body temperature.
Choice D rationale
Preventing hypothermia is a key reason for placing a newborn under a radiant heat warmer. However, the direct purpose of the warmer is to maintain the newborn’s body temperature.

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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

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer magnesium sulfate IV to a client who is in labor. Which of the following is the primary nursing assessment for this client?

Correct Answer is C

Explanation

What is the purpose of placing a newborn under a radiant heat warmer after birth?

Correct Answer is C

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.