A client with an obstetrical history of G1 P0000 received dinoprostone for cervical ripening 8 hours ago.
The Bishop score at that time was 4. The Bishop score is now 10. Which of the following actions by the nurse is appropriate?
Report abnormal findings to the obstetrician.
Place client on her side.
Monitor for onset of labor.
Perform nitrazine analysis of amniotic fluid.
The Correct Answer is C
Choice A rationale
Reporting abnormal findings to the obstetrician is unnecessary because an increase in the Bishop score from 4 to 10 indicates successful cervical ripening and readiness for labor
induction.
Choice B rationale
Placing the client on her side is not directly related to the assessment of cervical ripening or the Bishop score. It may be considered for comfort during labor.
Choice C rationale
Monitoring for the onset of labor is appropriate since the increase in the Bishop score to 10 suggests that the cervix is favorable for labor. Continuous monitoring is essential to detect
the onset and progression of labor.
Choice D rationale
Performing nitrazine analysis of amniotic fluid is not relevant to the assessment of cervical ripening or the Bishop score. This test is typically used to confirm the presence of amniotic
fluid in cases of suspected rupture of membranes.
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Correct Answer is D
Explanation
Choice A rationale
Reduction of fever is not a primary effect of carboprost tromethamine. This medication is primarily used to induce uterine contractions to manage postpartum hemorrhage.
Choice B rationale
While maintaining stable blood pressure is important, it is not the specific indicator of carboprost tromethamine's effectiveness. This medication is used to control bleeding.
Choice C rationale
Increased comfort, although significant, is not the direct effect of carboprost tromethamine. The primary aim is to induce uterine contractions to manage hemorrhage.
Choice D rationale
Decreased lochia rubra indicates the reduction of postpartum bleeding, which is the primary purpose of administering carboprost tromethamine. This outcome shows the medication is effective.
Correct Answer is D
Explanation
Choice A rationale
Placing a pacifier in the baby's mouth is inappropriate because it does not address the underlying cause of grunting, which can be a sign of respiratory distress.
Choice B rationale
Checking the baby's diaper is not relevant to assessing the cause of grunting. Grunting is usually related to respiratory issues rather than a dirty diaper.
Choice C rationale
Having the mother feed the baby is inappropriate because grunting may indicate respiratory distress. Feeding should be deferred until the baby's respiratory status is assessed and stabilized.
Choice D rationale
Assessing the respiratory rate is appropriate because grunting in a newborn can indicate respiratory distress. The nurse should evaluate the respiratory status to determine the need for further intervention.