A nurse in a labor unit is admitting a patient who reports experiencing painful contractions. The nurse determines that the contractions last for 1 minute and occur every 3 minutes.The nurse records the following vital signs: fetal heart rate of 130/min, maternal heart rate of 128/min, and maternal blood pressure of 92/54 mm Hg. What should the nurse prioritize doing next?
Notify the provider of the findings.
Ask the patient if she needs pain medication.
Have the patient void.
Position the patient with one hip elevated.
The Correct Answer is D
The correct answer is Choice D
Choice A rationale: Notifying the provider is important but not the first priority in this situation. The maternal hypotension (BP 92/54 mm Hg) and elevated maternal heart rate (128/min) suggest decreased perfusion, which can compromise uteroplacental blood flow. Immediate intervention is required before notifying the provider, especially if positioning can restore circulation and fetal oxygenation. Waiting to call without correcting the underlying cause may result in fetal distress or worsening maternal status.
Choice B rationale: While uncontrolled pain may contribute to elevated maternal heart rate, the hypotension and tachycardia suggest a more urgent hemodynamic imbalance. Pain management may become appropriate after stabilizing maternal circulation. Focusing on pain relief first delays essential interventions to improve perfusion, risking fetal compromise due to inadequate uteroplacental oxygen delivery. The fetal heart rate of 130/min is reassuring, but maternal circulation must be prioritized to sustain it.
Choice C rationale: A full bladder can contribute to uterine displacement, but there is no indication in the scenario that bladder distention is an issue. Voiding may be done later but does not address the immediate concern of maternal hypotension and compensatory tachycardia. Uteroplacental perfusion depends heavily on maternal blood pressure, and bladder status has secondary importance in the acute phase of circulatory compromise.
Choice D rationale: Elevating one hip improves venous return and cardiac output by relieving pressure on the inferior vena cava, which is compressed by the gravid uterus in the supine position. This correction reduces hypotension and restores uteroplacental perfusion. The maneuver is a first-line response for maternal hypotension in labor, helping stabilize both mother and fetus quickly. Fetal oxygen delivery depends on adequate maternal perfusion, which this position supports.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Uteroplacental insufficiency causes late decelerations due to reduced oxygenation, not mechanical pressure. It reflects placental dysfunction, not direct cranial compression effects.
Choice B rationale: Spontaneous rupture of membranes increases infection and labor risk but does not directly alter cerebral perfusion or trigger vagal responses linked to head compression.
Choice C rationale: Altered fetal cerebral blood flow results from cranial pressure during contractions, triggering vagal stimulation and early decelerations. This is the physiological response to head compression.
Choice D rationale: Umbilical cord compression causes variable decelerations due to transient blood flow obstruction, unrelated to cranial pressure or cerebral perfusion changes.
Correct Answer is D
Explanation
Choice A rationale
The palpability of the posterior fontanel is not related to the position of the fetus.
Choice B rationale
The level of the ischial spines refers to the station of the fetus, not its position.
Choice C rationale
The passage of the largest fetal diameter through the pelvic outlet is a stage of labor, not a fetal position.
Choice D rationale
This is the correct answer. The left occiput posterior position refers to the position of the fetal head.
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