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A nurse is assisting in evaluating a client's progress during labor.

Exhibits

Click to highlight the client findings that indicate the labor is progressing as expected. To deselect a finding, click on the finding again.

Nurses' Notes

1615:

Client is in the partial sitting position and is instructed to bear down during uterine contraction. Client reports the urge to defecate. There is increased bloody show and the cervix is 10 cm dilated. Contractions 5 min apart. Contractions strong on palpation.

Vital Signs

1615:

Temperature 39.1° C (102.4" F)

Respiratory rate 20/min

Heart rate 110/min

Blood pressure 100/74 mm Hg

Oxygen saturation 96%

Client reports the urge to defecate

There is increased bloody show

cervix is 10 cm dilated

Contractions strong on palpation

Temperature 39.1° C (102.4" F)

Heart rate 110/min

Answer and Explanation

The Correct Answer is ["A","B","C","D"]

Rationale for Correct Options:

Urge to defecate occurs as the fetal head descends further into the birth canal, putting pressure on the rectum and perineum. This is a common sign of the second stage of labor, indicating that the client is nearing delivery.
Increased bloody show results from cervical dilation and effacement as the capillaries in the cervix rupture. A greater amount of blood-tinged mucus is expected as labor progresses, particularly in the transition phase and early second stage.
Cervix 10 cm dilated confirms that the client has reached full cervical dilation, which is required for the second stage of labor to begin. Complete dilation allows for the passage of the fetus through the birth canal.
Contractions strong on palpation indicate effective uterine activity, which is necessary for fetal descent and expulsion. Strong contractions help in moving the baby downward and increasing pressure on the cervix.

Rationale for Incorrect Options:

A heart rate of 110/min is elevated compared to the client’s earlier readings (90/min at 0830, 110/min at 0845) and may indicate maternal stress or exertion from labor pain. While mild increases in maternal heart rate are expected during labor, tachycardia above 110/min warrants further evaluation, particularly in the presence of fever.
Temperature of 39.1°C (102.4°F). This temperature is abnormally high and suggests infection, such as chorioamnionitis, especially considering the prolonged rupture of membranes since 1900 the previous night. Normal maternal temperature may rise slightly during labor due to exertion, but fever above 38°C (100.4°F) is concerning and requires medical attention.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Anticipated:

Administer oxygen at 10 L/min via non-rebreather face mask as needed: The client has late decelerations, indicating possible fetal hypoxia. Providing supplemental oxygen can enhance placental oxygenation and improve fetal status.
Position the client in lateral side-lying position: This position improves uteroplacental perfusion by relieving compression of the inferior vena cava, which can help resolve late decelerations and improve fetal oxygenation.
Encourage the client to void every 2 hr: A full bladder can impede fetal descent and contribute to labor discomfort. Regular voiding helps prevent bladder distention and promotes labor progress.
Administer prophylactic IV antibiotic: The client is positive for Group B streptococcus (GBS), which necessitates prophylactic antibiotic administration during labor to reduce the risk of neonatal infection.
Evaluate the client for uterine tachysystole: The client's contractions have increased in frequency and intensity. Assessing for excessive uterine activity is critical to prevent fetal distress and complications such as uterine rupture.

Contraindicated:

Administer magnesium sulfate IV: Magnesium sulfate is used for seizure prophylaxis in preeclampsia or for tocolysis in preterm labor. The client does not have preeclampsia, and labor is at term, making this intervention unnecessary.

A. Prepare the client for a chest x-ray to verify catheter placement. B. Use clean technique when changing the catheter dressing C. Verify the amount of TPN solution the client is receiving every 4 hr. D. Place the client in Sims' position for catheter insertion.

Correct Answer is A

Explanation

A. Prepare the client for a chest x-ray to verify catheter placement. A chest x-ray is required after central venous catheter insertion to confirm proper placement before initiating total parenteral nutrition (TPN). Incorrect placement can lead to complications such as pneumothorax, arterial puncture, or catheter malposition, making verification essential for safe administration.
B. Use clean technique when changing the catheter dressing. Central venous catheter dressings require sterile technique, not clean technique, to prevent bloodstream infections. Proper infection control measures, including hand hygiene, chlorhexidine skin antisepsis, and sterile gloves, help minimize the risk of catheter-related bloodstream infections.
C. Verify the amount of TPN solution the client is receiving every 4 hr. TPN is typically monitored continuously, with infusion rates checked at least hourly to ensure proper administration. Regular assessments of fluid balance, glucose levels, and electrolyte status are also necessary to prevent complications such as hyperglycemia or fluid overload.
D. Place the client in Sims' position for catheter insertion. The preferred position for central venous catheter insertion is Trendelenburg or supine, which helps dilate the veins and reduces the risk of air embolism. Sims’ position (lying on the left side with the right knee flexed) is not appropriate for this procedure.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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