A nurse is assisting in the care of a client who is at 3 weeks of gestation. The client presents to the Labor and Delivery Unit in the early phase of active labor with contractions occurring every 3 to 4 minutes.

An 18-gauge needle is inserted in the left hand and oxytocin infusion is initiated.

An internal examination reveals a left occiput anterior (LOA) vertex, 4 cm dilation, complete effacement, and decelerations noted in the fetal heart rate (FHR) which decreases to 100/min with contractions, lasts 10 seconds, and returns to baseline within 20 seconds.

What condition is the client most likely experiencing, what are 2 actions the nurse should take to address that condition, and what are 2 parameters the nurse should monitor to assess the client’s progress?

The client is experiencing normal labor progression.

The nurse should continue monitoring contractions and fetal heart rate.

The nurse should ensure the client is comfortable and hydrated.

The nurse should monitor the client’s pain level and fluid intake

Answer and Explanation

Correct Answer : B,C

Choice A rationale:

While some of the client's findings are consistent with normal labor progression, the decelerations in the fetal heart rate (FHR) are concerning and indicate a potential problem. Normal labor progression would not typically involve FHR decelerations.

Choice B rationale:

Monitoring contractions and fetal heart rate: This is crucial to assess the client's labor progress and fetal well-being. The frequency, duration, and intensity of contractions, as well as the baseline FHR, variability, and presence of any decelerations, should be closely monitored. These parameters provide essential information about the adequacy of uterine contractions, fetal oxygenation, and potential need for interventions.

Choice C rationale:

Ensuring the client is comfortable and hydrated: Comfort measures can help the client cope with labor pain and anxiety, which can indirectly improve fetal oxygenation by reducing stress hormones. Hydration is essential for maintaining adequate blood flow to the placenta and fetus, supporting fetal well-being.

Choice D rationale:

While monitoring pain level and fluid intake is important, they are not the most immediate priorities in this situation. The priority is to address the potential fetal distress indicated by the FHR decelerations and ensure adequate uterine contractions and fetal oxygenation.

Additional notes:

The nurse should also notify the healthcare provider of the FHR decelerations and any other concerning findings.

Further interventions, such as changing the client's position, administering oxygen, or discontinuing the oxytocin infusion, may be necessary depending on the assessment findings and provider's orders.

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Correct Answer is A

Explanation

Choice A rationale:

Lochia pooling: When a woman lies in bed, gravity causes lochia to pool in the vagina. This can result in a larger amount of

lochia being expelled when she stands up or moves around.

Reassurance: Explaining this physiological process to the client can help to reassure her that the sudden increase in lochia is

normal and not a cause for alarm.

Validation: The nurse should validate the client's feelings of concern, as it is understandable for a new mother to be anxious

about any changes in her body after childbirth.

Education: The nurse should also provide education about lochia, including its typical characteristics, duration, and expected

changes. This can help the client to anticipate and understand her postpartum experience.

Choice B rationale:

Retained placenta: While retained fragments of the placenta can cause increased lochia, this is not the most common

this possibility, especially before further assessment.

Assessment and intervention: If there is a concern for retained placenta, the nurse would conduct a thorough assessment,

including fundal height, uterine tone, and lochia characteristics. Further interventions, such as ultrasound or manual

exploration of the uterus, may be necessary.

Choice C rationale:

Urinary tract infections (UTIs): UTIs can sometimes cause an increase in lochia, but they are not typically associated with a

sudden, large gush of lochia upon standing. Other symptoms of a UTI, such as burning with urination, urgency, or frequency,

would likely be present as well.

Assessment and intervention: If a UTI is suspected, the nurse would assess for urinary symptoms and collect a urine sample

for analysis. Antibiotic treatment would be initiated if a UTI is confirmed.

Choice D rationale:

Lochia progression: The amount of lochia generally decreases over time during the postpartum period. It is heaviest in the first

few days after delivery and gradually tapers off over the course of several weeks.

Inconsistency with presentation: While this statement is true, it does not directly address the client's concern about a sudden

A. A client who has preeclampsia has 2+ patellar reflex and 2+ proteinuria B. A client who is at 24 weeks of gestation C. A client who has preeclampsia D. A client who has a heart rate of 100/min

Correct Answer is A

Explanation

Choice A rationale:
2+ patellar reflex: A hyperactive patellar reflex (also known as a knee-jerk reflex) is a sign of hyperreflexia, which can be a neurological symptom of preeclampsia. Hyperreflexia results from heightened nerve excitability and can manifest as exaggerated reflexes. In preeclampsia, it stems from central nervous system irritability due to cerebral edema or other neurological disturbances.
2+ proteinuria: Proteinuria, defined as the presence of excessive protein in the urine, is a hallmark sign of preeclampsia. It indicates glomerular damage in the kidneys, leading to protein leakage into the urine. The degree of proteinuria is graded on a scale of 1+ to 4+, with 2+ representing a significant level that warrants immediate attention.

Choice B rationale:
24 weeks of gestation: While 24 weeks of gestation is considered early preterm birth, it is not inherently a finding that requires immediate reporting to the RN in the context of postpartum care. The focus on the postpartum unit is primarily on the health of the mother and newborn after delivery, rather than managing ongoing pregnancies.

Choice C rationale:
Preeclampsia: While preeclampsia is a serious condition that necessitates close monitoring and management, the mere diagnosis of preeclampsia without additional concerning findings does not automatically require immediate reporting to the RN. It's essential to assess for specific signs and symptoms that indicate worsening or complications of preeclampsia, such as those mentioned in Choice A.

Choice D rationale:
Heart rate of 100/min: A heart rate of 100 beats per minute is within the normal range for adults, even postpartum. Mild tachycardia (increased heart rate) can be a physiological response to various factors such as pain, anxiety, or exertion, and it does not always signify a serious problem. However, if the heart rate is persistently elevated or accompanied by other concerning symptoms, it would warrant further evaluation.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting a client out of bed for the first time since delivery. The client becomes frightened when she passes a large amount of lochia.Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a group of clients on a postpartum unit. Which of the following findings should be reported to the RN immediately?

Correct Answer is A

Explanation

A nurse is caring for a postpartum client who saturates a perineal pad in 10 min.Which of the following actions should the nurse take first?

A nurse is caring for a client who is 1 day postpartum following a cesarean birth.To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client’s care?

A nurse is collecting data from a client who is 3 days postpartum and is breastfeeding. Her lochia rubra is moderate, and her breasts feel hard and warm.Which of the following recommendations should the nurse give the client?

A nurse is reinforcing teaching about reducing the risk of perineal infection with a client who had a vaginal birth. Which of the following information should the nurse include in the teaching? (Select all that apply.)

A nurse is caring for a client 2 hours following a spontaneous vaginal delivery and notes that the client has saturated two perineal pads with blood in a 30-minute period.Which of the following actions should the nurse take first?

A nurse is assisting with the care of a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client who is in labor.Which of the following findings should the nurse report to the provider?

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hours ago.The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?