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 D
Explanation
Choice A rationale
Hyperglycemia, or high blood sugar, is a condition that is most commonly seen in individuals with diabetes. Symptoms can include frequent urination, increased thirst, and increased hunger. If left untreated, it can lead to serious complications such as diabetic ketoacidosis.
Choice B rationale
Anemia is a condition characterized by a decrease in the total amount of red blood cells or hemoglobin in the blood, or a lowered ability of the blood to carry oxygen. Symptoms can include fatigue, weakness, pale or yellowish skin, irregular heartbeats, shortness of breath, dizziness or lightheadedness, and chest pain.
Choice C rationale
Type 1 diabetes mellitus is a chronic condition in which the pancreas produces little or no insulin, a hormone needed to allow sugar (glucose) to enter cells to produce energy. The far more common type 2 diabetes occurs when the body becomes resistant to insulin or doesn’t make enough insulin.
Choice D rationale
Hypertension, or high blood pressure, is a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease. If the nurse is reviewing the client’s medical records and actions to be taken, it is likely that the client is experiencing hypertension.
Correct Answer is B
Explanation
Choice A rationale
While the client’s daughter, who is the primary caregiver, may have a significant role in the client’s care, the decision to sign the informed consent ultimately lies with the client if they are deemed competent.
Choice B rationale
The client, who is alert and oriented to person, place, and time, and has advance directives, is the most appropriate person to sign the informed consent. As long as the client is competent and understands the information provided, they have the right to make their own medical decisions.
Choice C rationale
The client’s partner does not have the legal authority to sign the informed consent on behalf of the client unless the client is deemed incompetent and the partner is designated as the legal representative.
Choice D rationale
The client’s son, who has a durable power of attorney, can only sign the informed consent on behalf of the client if the client is deemed incompetent. Since the client is alert and oriented, they should be the one to sign the informed consent.
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