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 A
Explanation
Choice A rationale
Facial edema, or swelling in the face, can be a sign of a serious complication during pregnancy, such as preeclampsia. Preeclampsia is a condition characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys.
Choice B rationale
Leukorrhea, or a thick, milky discharge from the vagina, is a common and normal symptom of pregnancy. It is not typically a sign of a complication.
Choice C rationale
Nausea and vomiting are common symptoms during the first trimester of pregnancy. However, severe or persistent nausea and vomiting can indicate a condition called hyperemesis gravidarum, which requires medical attention.
Choice D rationale
Urinary frequency is a common symptom during pregnancy and is not typically a sign of a complication.
Correct Answer is A
Explanation
Choice A rationale
Magnesium sulfate is used in preterm labor to suppress contractions and delay the birth of a preterm baby. It works by lowering the amount of calcium in the uterine muscles, which in turn encourages muscle relaxation. This effect can help slow or inhibit contractions, allowing more time for the administration of corticosteroids before birth. Corticosteroids can improve a baby’s lung function and reduce the risk of dying by 40 percent if given within 48 hours. Therefore, magnesium sulfate is used to stop preterm labor contractions.
Choice B rationale
Magnesium sulfate does not directly increase the fetal heart rate. Its primary role in the context of preterm labor is to inhibit contractions.
Choice C rationale
While magnesium sulfate is used in the context of preterm labor, it does not directly promote fetal lung maturity. However, by delaying delivery, it allows more time for the administration of corticosteroids, which can enhance the baby’s lung function.
Choice D rationale
While magnesium sulfate can have a muscle-relaxing effect, its primary use in the context of preterm labor is not to promote relaxation or alleviate anxiety in the mother. Its main role is to inhibit uterine contractions.
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