A 28-year-old female client is in the second stage of labor in the maternity ward.
A nurse is caring for a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
The Correct Answer is []
The client is most likely experiencing Normal labor progression. The retraction of the fetal head against the maternal perineum, regular and progressing contractions, and full dilation of the cervix are all signs of normal labor progression.
Actions: The nurse should:
1. Encourage the client to push during contractions. This will help the baby move down the birth canal.
2. Monitor fetal heart rate. This is crucial to ensure the baby is not in distress.
Parameters: The nurse should monitor:
1. Frequency of contractions. This will help assess the progress of labor.
2. Fetal heart rate. Any abnormalities could indicate fetal distress, which would require immediate medical attention.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale
Methylergonovine is a medication that is primarily used to prevent or treat excessive bleeding after childbirth. It works by increasing the rate and strength of contractions and the stiffness of the uterus muscles, which helps to decrease bleeding. This medication is given in a hospital or clinic setting. Therefore, the nurse should inform the client that this medication is intended to prevent postpartum hemorrhage.
Choice B rationale
While preventing postpartum infection is important, methylergonovine is not specifically used for this purpose. Postpartum infection is typically prevented and treated with antibiotics and good hygiene practices.
Choice C rationale
Thromboembolic events, such as blood clots, can be a risk after childbirth. However, methylergonovine is not used to prevent these events. Anticoagulant medications are typically used to prevent thromboembolic events.
Choice D rationale
Methylergonovine is not used to prevent hypertension. In fact, it can cause increased blood pressure as a side effect. Therefore, it would not be used as a preventative measure for hypertension.
Correct Answer is A
Explanation
The priority finding for a nurse caring for a client receiving opioid epidural analgesia during labor would be a blood pressure of 80/56 mm Hg. This could indicate hypotension, a known side effect of epidural analgesia. Hypotension can lead to decreased perfusion to vital organs, including the placenta, potentially compromising the fetus. Immediate interventions might include positioning the patient on her side, increasing the rate of IV fluids, and notifying the healthcare provider.
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