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Exhibits

Which actions should the nurse take? Select all that apply.

Assist the client to the left lateral position.

Administer oxygen at 10 L/min via nonrebreather face mask.

Notify the provider of the client's condition.

Request a prescription for oxytocin.

Request a prescription for hydralazine.

Prepare to administer an amnioinfusion.

Initiate a bolus of IV fluid.

Answer and Explanation

Correct Answer : A,B,C,F,G

A. Assist the client to the left lateral position: Repositioning improves uteroplacental perfusion, especially in the presence of variable decelerations. The left lateral position relieves pressure on the inferior vena cava, promoting fetal oxygenation.

B. Administer oxygen at 10 L/min via nonrebreather face mask: Oxygen is indicated to improve fetal oxygenation during nonreassuring FHR patterns like recurrent variable decelerations and minimal variability, both of which are present in this scenario.

C. Notify the provider of the client's condition: The combination of recurrent variable decelerations, minimal variability, and a history of meconium-stained fluid warrants immediate provider notification to assess further interventions and potential fetal compromise.

D. Request a prescription for oxytocin: Oxytocin stimulates uterine contractions and may worsen fetal distress in the presence of variable decelerations or minimal variability. It is contraindicated until the fetal status is stabilized.

E. Request a prescription for hydralazine: Hydralazine is used to treat hypertension. The client’s blood pressure is within normal range and does not require antihypertensive management at this time.

F. Prepare to administer an amnioinfusion: Amnioinfusion is indicated to dilute meconium-stained amniotic fluid and relieve cord compression, both of which are suggested by the variable decelerations and green-stained fluid earlier.

G. Initiate a bolus of IV fluid: IV fluid bolus improves maternal blood volume and uteroplacental perfusion, which can help resolve variable decelerations and increase fetal oxygenation during nonreassuring FHR patterns.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Povidone-iodine:Although effective for skin disinfection, povidone-iodine requires a long drying time and is not the preferred agent for disinfecting the access port of central lines. It is more commonly used for preparing the skin before catheter insertion, not for port access.

B. Hydrogen peroxide:Hydrogen peroxide is not recommended for disinfecting central venous access devices due to its cytotoxic properties and potential to damage catheter materials. It can also irritate tissue and is not effective against all organisms.

C. 2% chlorhexidine:Chlorhexidine is the preferred antiseptic for disinfecting central venous catheter ports. It offers rapid, broad-spectrum antimicrobial action and prolonged residual activity, making it ideal for preventing catheter-related bloodstream infections.

D. 70% alcohol solution:Alcohol is commonly used but lacks the persistent antimicrobial activity of chlorhexidine. While it can reduce surface microbes, it is less effective at preventing infection over time compared to 2% chlorhexidine.

A. Offer the client oral fluids. B. Check the client's IV site. C. Obtain the client's oxygen saturation level. D. Determine the client's level of consciousness.

Correct Answer is C

Explanation

A. Offer the client oral fluids:Fluids should not be offered until the client’s gag reflex has returned to prevent aspiration. Offering fluids too soon after a bronchoscopy places the client at significant risk for aspiration pneumonia due to airway suppression from sedation.

B. Check the client’s IV site:While important, this is not the priority in the immediate post-procedure period. IV site assessment ensures patency and absence of complications, but it does not address the client’s airway or oxygenation status, which are more urgent concerns.

C. Obtain the client’s oxygen saturation level:Airway and oxygenation take top priority following sedation and bronchoscopy, especially since the procedure can cause respiratory depression or airway compromise. Measuring oxygen saturation is essential to detect early hypoxia and ensure respiratory stability.

D. Determine the client’s level of consciousness:While evaluating consciousness is important after moderate sedation, it comes after assessing oxygenation. A decreased oxygen level could lead to altered mental status, so it’s more critical to assess oxygenation first.

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Exhibits Which actions should the nurse take? Select all that apply.

Nursing Test Bank

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Exhibits

Which actions should the nurse take? Select all that apply.