A nurse in the labor unit is admitting a patient who reports experiencing painful contractions.
The nurse determines that the contractions last 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 is the nurse’s priority action?
Have the patient void.
Ask the patient if she needs pain medication.
Turn the patient on her side and recheck the blood pressure.
Notify the healthcare provider of the findings.
The Correct Answer is C
Choice A rationale
Having the patient void is not the immediate priority. While it is important to ensure the bladder is not distended, which could interfere with labor progress, the vital signs suggest a more urgent concern.
Choice B rationale
Asking the patient if she needs pain medication is important for comfort measures during labor, but it is not the immediate priority. The nurse’s first responsibility is to ensure the safety of the mother and baby.
Choice C rationale
Turning the patient on her side and rechecking the blood pressure is the correct action. The maternal blood pressure is low, which could indicate supine hypotensive syndrome. This occurs when the gravid uterus compresses the inferior vena cava when the woman is supine, reducing venous return to the heart. Turning the woman on her side may relieve this pressure and improve blood pressure.
Choice D rationale
Notifying the healthcare provider of the findings is important, but it is not the first action the nurse should take. The nurse should first address the mother’s hypotension by turning her on her side.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hematuria, or blood in the urine, is not typically a symptom of postpartum endometritis.
Choice B rationale
Pelvic pain is a common symptom of postpartum endometritis. It is often one of the first symptoms to appear, along with lower abdominal pain and uterine tenderness.
Choice C rationale
While a moderate amount of dark red lochia with a bloody odor can be a normal part of the postpartum period, it is not specifically indicative of endometritis.
Choice D rationale
Localized area of breast tenderness is not typically a symptom of postpartum endometritis.
Correct Answer is D
Explanation
Choice A rationale
Sleeping on the left side does not directly help manage GERD. While it might help with digestion due to the positioning of the stomach, it is not a primary recommendation for GERD management.
Choice B rationale
Drinking milk is not a recommended way to soothe the stomach for a GERD patient. While milk might provide temporary relief from acid reflux, it could potentially stimulate the stomach to produce more acid, which can exacerbate GERD symptoms.
Choice C rationale
Waiting to go to bed for 1 hour after eating can help manage GERD. However, it is generally recommended to wait 2-3 hours after eating before lying down. This allows time for the stomach to empty and reduces the chance of stomach acid backing up into the esophagus.
Choice D rationale
Eating four to six small meals each day is a recommended way to manage GERD. Smaller meals are easier on the stomach, as they require less acid for digestion. This can help reduce the symptoms of GERD12.
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