A client at 37 weeks gestation presents with contractions every 3 to 4 minutes, lasting 60 seconds.
The fetal heart rate is noted to be 140 bpm, and no abnormal fetal movements are observed.
The client reports no pain and normal laboratory results.
Which action should the nurse implement first?

Administer oxygen.

Check cervical dilation.

Start an intravenous fluid bolus.

Prepare for immediate delivery.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Administering oxygen would not be the priority as the fetal heart rate is normal and there are no abnormal fetal movements or signs of distress. Oxygen administration is typically reserved for cases where there is evidence of fetal hypoxia or distress.

Choice B rationale

Checking cervical dilation is essential as it provides critical information about the progress of labor and helps in determining the next steps in management. It ensures that the labor is progressing appropriately and identifies if there is a need for any medical interventions.

Choice C rationale

Starting an intravenous fluid bolus would not be the first action in this scenario as the client does not show signs of dehydration or hypotension. Fluid bolus is generally reserved for cases where there is evidence of hypovolemia or to support hemodynamic stability.

Choice D rationale

Preparing for immediate delivery is not necessary at this stage as there are no signs of fetal distress or urgent complications. The client is only 37 weeks gestation and regular assessment is crucial to ensure timely and appropriate interventions without premature actions.

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Correct Answer is B

Explanation

Choice A rationale

While heartburn is common during pregnancy due to hormonal changes and pressure from the growing uterus, the presence of 3+ bilateral pitting pedal edema raises concerns. This symptom could indicate a more serious condition, such as preeclampsia, and should not be dismissed as a normal discomfort.

Choice B rationale

Asking if blurred vision and headache have occurred is essential because these symptoms, along with significant edema, are indicators of preeclampsia. Preeclampsia is a serious pregnancy complication characterized by high blood pressure and damage to other organ systems, often requiring immediate medical attention.

Choice C rationale

Checking urine for glucose and ketones is relevant for assessing gestational diabetes but does not address the immediate concern of preeclampsia. The symptoms of edema and possible preeclampsia should be prioritized over concerns of gestational diabetes.

Choice D rationale

Instructing the client to take an antacid for heartburn does not address the critical issue of significant edema. While heartburn relief is important, the symptoms of edema need immediate evaluation to rule out preeclampsia or other complications.

A. Assess the fetal heart rate and client's contraction pattern. B. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration. C. Determine fetal position by performing Leopold maneuvers. D. Perform sterile vaginal examination to determine dilatation.

Correct Answer is A

Explanation

Choice A rationale

Assessing the fetal heart rate and client's contraction pattern is the highest priority when a large amount of bright red vaginal bleeding occurs. It is crucial to evaluate fetal well-being and the progression of labor to determine any immediate interventions needed to ensure the safety of both the mother and fetus.

Choice B rationale

Confirming Rh and Coombs status for Rho(D) immunoglobulin administration is important for Rh-negative mothers, but it is not the immediate priority in the presence of significant vaginal bleeding. Ensuring fetal and maternal stability takes precedence over Rh status confirmation.

Choice C rationale

Determining fetal position by performing Leopold maneuvers is not the highest priority when there is significant vaginal bleeding. While fetal position is relevant, immediate assessment of fetal heart rate and maternal contraction pattern is more critical for evaluating the urgency of the situation.

Choice D rationale

Performing a sterile vaginal examination to determine dilation is contraindicated in the presence of vaginal bleeding, as it can exacerbate the situation and lead to further complications. Immediate assessment of fetal well-being and maternal condition is more crucial before considering any internal examination. .

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A client at 37 weeks gestation presents with contractions every 3 to 4 minutes, lasting 60 seconds.The fetal heart rate is noted to be 140 bpm, and no abnormal fetal movements are observed.The client reports no pain and normal laboratory results.Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a prenatal visit, a client at 30 weeks gestation reports persistent heartburn during the past two weeks.The nurse notes the client has 3+ bilateral, pitting, pedal edema.Which action should the nurse implement?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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A client at 37 weeks gestation presents with contractions every 3 to 4 minutes, lasting 60 seconds.
The fetal heart rate is noted to be 140 bpm, and no abnormal fetal movements are observed.
The client reports no pain and normal laboratory results.
Which action should the nurse implement first?