NCLEX-Style Questions, Comprehensive Review &
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1.A nurse iscaring for aclient who is42 weeks ofgestation. Medical
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History
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29-year-old client admitted this morning for induction of labor. Gravida 2 Para v v v v v v v v v v v
1. Had an uncomplicated spontaneous vaginal birth 3 years ago of a 7 lb 4 oz infant.
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Client has no outstanding medical, social, or surgical history. Plan is to induce labor
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using oxytocin
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Based on the assessment findings, which of the following actions should the
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nurse plan to take? Click to specify whether the nurse's planned actions are
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anticipated, nonessential, or contraindicated.: Increase the oxytocin infusion to 13 mu/min is
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contraindicated. This client has a category 3 fetal heart rate tracing indicating absent baseline variability and either late, or
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recurrent variable decelerations. Increasing the oxytocin infusion would likely cause a further decline in fetal well-being.
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Therefore,thenurseshouldstoptheinfusionofoxytocin,notincreasetherateofinfusion.
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Placeclientinaside-lyingpositionisanticipated.
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Initiate bolus of primary IV fluids is anticipated. This client has a category 3 fetal heart rate tracing These findings are consistent
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with manifestations associated with fetal hypoxia. Initiating a bolus of the primary IV fluids increases the client's blood volume
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which increases their oxygenation and cardiac output, thereby increasing blood flow and oxygenation to the fetus.
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Apply oxygen at 10 L/min via venturi mask is contraindicated. The nurse should apply oxygen at 10 L/min via a nonrebreather
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mask, not a venturi mask..
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Perform sterile vaginal examination (SVE) is anticipated. This client has a category 3 fetal heart rate tracing indicating absent
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baseline variability and either late, or recurrent variable decelerations. These findings are consistent with findings associated
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with fetal hypoxia and could be caused by a prolapsed umbilical cord; therefore, the nurse should perform a SVE to assess for the
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presence of a hidden prolapsed umbilical cord.
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AssignaBishopscoreisnonessential.A Bishopscore isusedtoassessthecervix priortoinductionoflaborto determine the
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likelihood of a vaginal delivery.
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Perform an amniotomy is contraindicated.
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, 2. A nurse in an antepartum clinic is caring for a client who is pregnant.
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Nurses' Notes
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1200:
Client is placed on electronic fetal monitor. Fetal heart tones (FHT) 150/min.
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Abdominal soft and nontender. Client reports, "I have been cramping since
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2/10
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