Difficulty: Medium
Average Score: 88%
Simulated
Passage / Scenario
Nurses' Notes: Client at 38 weeks of gestation presents with fluid leaking from vagina. Mild contractions 20 min apart at 0630, 15 min apart at 0830. Cervix 2 cm dilated, 20% effaced. FHR 132/min with moderate variability.After review of the client's EMR, which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?
Correct answer
A, D, E, G; B, F; C
Rationale
A: Anticipated - helps labor progress; B: Non-essential - no indication for catheterization; C: Contraindicated - risks supine hypotensive syndrome; D, E, G: Anticipated - monitor fetal well-being and confirm membrane rupture.