A nurse on an antepartum unit is caring for a 32-year-old female client at 28 weeks gestation.

Exhibits

For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client. There must be at least one selection in every row. There does not need to be a selection in every column.

Administration of IV fluids

Continuous monitoring of FHR

Abdominal ultrasound

Digital cervical exam to assess dilation and effacement

Laboratory testing: CBC, Blood Type & Rh, Coagulation Studies

Placement of an internal fetal spiral electrode

Administration of betamethasone

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}

Administration of IV fluids: This is anticipated as it ensures the client remains well-hydrated, which is important for both maternal and fetal health.
Continuous monitoring of FHR: This is anticipated to monitor the fetal well-being and ensure there are no signs of fetal distress.
Abdominal ultrasound: This is anticipated to assess fetal growth, amniotic fluid levels, and placental positioning.
Digital cervical exam to assess dilation and effacement: This is contraindicated because frequent cervical exams can increase the risk of infection and may cause unnecessary discomfort, especially if there are no signs of labor.
Laboratory testing: CBC, Blood Type & Rh, Coagulation Studies: These tests are anticipated to provide important information about the client's blood count, blood type, Rh status, and coagulation parameters, which are crucial for managing potential complications.
Placement of an internal fetal spiral electrode: This is contraindicated as it is an invasive procedure that carries risks, and it is unnecessary given that the FHR is within normal limits with external monitoring.
Administration of betamethasone: This is anticipated as betamethasone is often given to promote fetal lung maturity in cases where there is a risk of preterm birth.

Nursing Test Bank

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Correct Answer is B

Explanation

Choice A rationale

Cesarean birth is not necessarily required for GBS-positive clients as long as IV antibiotic prophylaxis is administered during labor to prevent transmission to the newborn.

Choice B rationale

IV antibiotic prophylaxis, typically with penicillin or ampicillin, is given to GBS-positive clients during labor to prevent neonatal GBS infection.

Choice C rationale

Obtaining a vaginal culture at 39 weeks of gestation is not necessary if the client was already screened and found positive for GBS at 36 weeks.

Choice D rationale

Metronidazole is used to treat bacterial vaginosis or trichomoniasis, not GBS infection; thus, it is not appropriate for this scenario. .

A. A client who has an indwelling urinary catheter. B. A client who has a second-degree perineal laceration. C. A client who is saturating a perineal pad every 5 to 6 hr. D. A client who is experiencing breast engorgement.

Correct Answer is A

Explanation

Choice A rationale

An indwelling urinary catheter can increase the risk of falls because it may cause discomfort and restricted mobility, leading the client to move awkwardly or lose balance.

Choice B rationale

While a second-degree perineal laceration might cause pain and limited mobility, it doesn't usually contribute as significantly to fall risk as an indwelling catheter.

Choice C rationale

Saturating a perineal pad every 5 to 6 hours may indicate heavy postpartum bleeding, but it isn't directly related to fall risk. The concern here would be more about monitoring for hemorrhage rather than falls.

Choice D rationale

Breast engorgement causes discomfort and pain but doesn't directly affect a client's mobility or balance, making it less likely to increase fall risk.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is at 39 weeks of gestation and in active labor.The client reports being positive for group B streptococcus (GBS) when screened at 36 weeks of gestation.Which of the following actions should the nurse expect to take?

Correct Answer is B

Explanation

A nurse is caring for a group of clients who are postpartum.Which of the following clients is at an increased risk for a fall?

Correct Answer is A

Explanation

A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation and has a history of anemia.Which of the following results should the nurse identify and report as an indication of a prenatal complication?

A nurse is teaching a class to clients who are pregnant.Which of the following topics should the nurse include in the discussion about cesarean birth? (Select all that apply.)

A nurse is caring for a postpartum client who is breastfeeding their newborn and reports that their nipples have become sore and cracked.Which of the following statements should the nurse make?

A nurse is assessing a client who is in active labor.The client reports back labor pains.Which of the following nonpharmacological interventions should the nurse provide to manage the client's pain?

A nurse is teaching a client about iron supplementation during pregnancy.Which of the following client statements indicates an understanding of the teaching?

A nurse is assessing a client who is in labor.Which of the following findings should the nurse expect?

A nurse is planning care for a newborn who was exposed to active genital herpes simplex virus (HSV) during birth.Which of the following nursing actions should the nurse anticipate?

A nurse is assessing a client who is at 33 weeks of gestation.Which of the following findings should the nurse report to the provider?