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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Chicken pox: Chicken pox (varicella) typically presents with a vesicular rash starting on the trunk and spreading to the face and extremities. It does not cause bluish-white spots on the buccal mucosa and rarely appears without skin lesions.
B. Roseola: Roseola (sixth disease) is characterized by a high fever followed by a sudden rose-colored rash as the fever subsides. It does not cause lesions in the mouth such as Koplik spots, which are associated with measles.
C. Measles: Bluish-white spots on the buccal mucosa, known as Koplik spots, are a hallmark sign of measles and often appear before the characteristic maculopapular rash. This early sign helps identify the disease even when no other symptoms are present.
D. Erythema infectiosum: Also known as fifth disease, this condition usually presents with a "slapped cheek" facial rash followed by a lacy rash on the body. It does not produce oral lesions like the buccal mucosa spots seen in measles.
Correct Answer is B
Explanation
A. Dry mouth: Dry mouth is a common and generally mild side effect of sertraline and other SSRIs. It can typically be managed with increased fluid intake or sugar-free lozenges and does not suggest a medical emergency.
B. Excessive sweating: Excessive sweating, especially when accompanied by symptoms such as confusion, agitation, muscle rigidity, or fever, may indicate serotonin syndrome. This is a potentially life-threatening condition and requires immediate medical evaluation.
C. Constipation: Constipation is a possible side effect of many antidepressants, including sertraline. However, it is not associated with serotonin syndrome and can often be managed with dietary changes or mild laxatives.
D. Insomnia: Insomnia is a known, non-urgent side effect of sertraline that may improve over time or be managed with sleep hygiene techniques. It does not indicate the presence of serotonin syndrome.
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