Scenario:

A nurse is caring for a 26-year-old gravida 2 para 1 female client in the labor and delivery unit. The client previously delivered vaginally three years ago under epidural anesthesia. Her current pregnancy has progressed normally with a weight gain of 28 lbs (12.7 kg) and no reported blood pressure issues. Group B Streptococcus screening is negative, and all pregnancy-related laboratory results, including rubella immunity, are within normal limits. The client has a blood type of O, Rh-positive.

Exhibits

The nurse teaches the client about the fetus's reaction to labor by:

Select the most appropriate options missing from the statements below. Describing heart rate patterns by
dropdown
Evaluating the relationship when a contraction occurs by
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Complete the sentence: The nurse teaches the client about the fetus's reaction to labor by explaining that early decelerations indicate head compression and assessing fetal heart rate patterns before, during, and after contractions.

Rationale for correct answer: Explaining that early decelerations indicate head compression is correct because early decelerations are typically associated with head compression during contractions. This is a common finding during labor and usually not a sign of fetal distress. It indicates that the fetus is descending through the birth canal, causing temporary compression of the fetal head, which leads to a brief decrease in heart rate.

Assessing fetal heart rate patterns before, during, and after contractions is correct because it provides a comprehensive understanding of how the fetus responds to labor. Monitoring the fetal heart rate throughout the contraction cycle helps identify patterns of variability, decelerations, and accelerations, ensuring that the fetus is tolerating labor well.

Rationale for incorrect answers: Choice A rationale: Identifying early decelerations as a sign of fetal distress is incorrect because early decelerations are generally benign and related to head compression. They are not typically a sign of fetal distress. Late or variable decelerations are more concerning and may indicate fetal distress.

Choice C rationale: Stating that early decelerations require immediate intervention is incorrect because early decelerations do not usually require immediate intervention. They are a normal finding during labor caused by head compression. Interventions are necessary for late or variable decelerations, which indicate possible fetal compromise.

Choice D rationale: Noting that early decelerations suggest umbilical cord compression is incorrect because early decelerations are not typically associated with umbilical cord compression. Variable decelerations are more likely to indicate cord compression, requiring closer monitoring and possible intervention.

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

Explanation

Interventions	Support Epidural Anesthesia for Mother	Support Epidural Anesthesia for Fetus
Assisting with pushing efforts	✓
Administering bolus fluids	✓
Monitoring blood pressure	✓	✓
Administering IV fluids	✓
Side positioning	✓	✓

Assisting with pushing efforts:

Goal: Support Epidural Anesthesia for Mother
Reason: Epidural anesthesia can diminish the mother's ability to feel the urge to push during labor. Assisting with pushing efforts helps ensure effective delivery and supports the mother's ability to participate actively in the birthing process.

Administering bolus fluids:

Goal: Support Epidural Anesthesia for Mother
Reason: Administering bolus fluids can help prevent hypotension, a common side effect of epidural anesthesia. Ensuring adequate fluid volume maintains blood pressure and supports overall maternal hemodynamic stability.

Monitoring blood pressure:

Goal: Support Epidural Anesthesia for Mother and Fetus
Reason: Continuous monitoring of blood pressure is essential to detect and manage hypotension, ensuring both maternal and fetal well-being. It helps maintain adequate blood flow to the uterus and placenta, optimizing fetal perfusion.

Administering IV fluids:

Goal: Support Epidural Anesthesia for Mother
Reason: Administering IV fluids helps maintain hydration and blood pressure, counteracting the potential hypotensive effects of epidural anesthesia. It supports the mother's hemodynamic stability during labor.

Side positioning:

Goal: Support Epidural Anesthesia for Mother and Fetus
Reason: Side positioning optimizes uteroplacental blood flow and reduces the risk of aortocaval compression by the gravid uterus. It ensures better fetal perfusion and maternal comfort while receiving epidural anesthesia.

A. Develop a safety plan. B. Perform a thorough physical assessment. C. Report findings to Adult Protective Services. D. Confront the abuser about concerning actions. E. Take photographs to document the abuse or neglect. F. Complete a comprehensive history. G. Throw away soiled clothing. H. Query the client in front of the suspected abuser.

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

Explanation

Choice A rationale: Developing a safety plan is essential to ensure the client's immediate and long-term safety. This involves planning for safe living arrangements and other protective measures.

Choice B rationale: Performing a thorough physical assessment helps document the extent of injuries or neglect and provides critical information for further actions and interventions.

Choice C rationale: Reporting findings to Adult Protective Services is a necessary step to ensure that the client receives the appropriate protection and support from authorities.

Choice E rationale: Taking photographs to document the abuse or neglect provides visual evidence that can be used in investigations and legal actions to protect the client.

Choice F rationale: Completing a comprehensive history helps understand the full context of the client's situation, including past medical history, social support, and potential risk factors for mistreatment.

Choice D rationale: Confronting the abuser about concerning actions is not advisable as it can escalate the situation and put the client at greater risk.

Choice G rationale: Throwing away soiled clothing may destroy potential evidence and is not a priority intervention in the context of suspected elder mistreatment.

Choice H rationale: Querying the client in front of the suspected abuser can intimidate the client and prevent them from speaking freely about their situation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A nurse is caring for an 84-year-old female client in her home to establish home health care and perform an initial assessment. Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

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

Explanation

A nurse is caring for a 24-year-old female client in the emergency department (ED). Exhibits What is the most likely diagnosis for this client, based on the history, physical exam, and diagnostic results?

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

Exhibits The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.

A nurse is monitoring a client receiving a blood transfusion. Which of the following actions should the nurse take first?

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?