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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Oxygen administration is not indicated in this situation. The client's vital signs are stable, and there is no evidence of
respiratory distress.
Oxygen administration could potentially mask signs of postpartum hemorrhage, which is a serious complication.
It is important to assess the client's respiratory status closely, but oxygen should not be administered unless there is a clear
indication for it.
Choice B rationale:
Methylergonovine is a medication that is used to treat postpartum hemorrhage.
It works by contracting the uterus and reducing blood flow.
However, it is a potent medication that can have serious side effects, such as hypertension and seizures.
It is important to clarify the order with the provider before administering this medication.
The provider may want to assess the client further or consider other options before ordering methylergonovine.
Choice C rationale:
Inserting a urinary catheter is not necessary in this situation.
The client is not experiencing any urinary problems, and there is no evidence of bladder distention.
Catheterization can increase the risk of urinary tract infection, so it should only be performed when there is a clear indication
for it.
Choice D rationale:
Increasing the infusion rate of the IV fluid may be helpful in some cases of postpartum hemorrhage.
However, it is important to assess the client's fluid status before increasing the infusion rate.
Too much fluid can lead to pulmonary edema, which is a serious complication.
Correct Answer is A
Explanation
The correct answer is Choice A
Choice A rationale: A distended bladder can displace the uterus upward and to the side, preventing proper uterine involution and increasing risk of postpartum hemorrhage.
Choice B rationale: Blood pressure of 130/84 mm Hg is within normal postpartum range and does not indicate urinary retention or bladder distention.
Choice C rationale: Moderate lochia rubra is expected postpartum and reflects normal uterine shedding, not urinary status.
Choice D rationale: Moderate labial swelling may occur from delivery trauma but does not directly indicate bladder fullness or urinary retention.
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