A nurse is assisting in the care of a client who is at 38 weeks of gestation.
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 preterm labor.
The nurse should administer prescribed medication and encourage bed rest.
The nurse should monitor contraction frequency and fetal heart rate.
The Correct Answer is B
Choice A is incorrect. Preterm labor is defined as uterine contractions that occur before 37 weeks of gestation. The
client in this case is at 38 weeks of gestation, which is considered term gestation. Therefore, preterm labor is not the
most likely condition the client is experiencing.
Rationale for Choice B
Choice B is partially correct. While bed rest may be recommended for some clients experiencing certain conditions
during pregnancy, it is not the most appropriate intervention for all clients at 38 weeks of gestation. Additionally,
administering medication without knowing the specific condition the client is experiencing is not safe or ethical.
Rationale for Choice C
Choice C is correct. Monitoring contraction frequency and fetal heart rate are two of the most important actions a
nurse can take to assess a client at 38 weeks of gestation. These parameters can provide valuable information about
the client's progress and help to identify any potential problems.
Explanation:
At 38 weeks of gestation, the client is considered to be at term. This means that she is full-term and her baby is ready
to be born. However, even at term, there are a number of conditions that can occur that may require nursing
intervention.
One of the most common conditions that can occur at term is labor. Labor is the process by which the uterus contracts
and dilates to push the baby out of the birth canal. The nurse should monitor the client for signs and symptoms of
labor, such as:
Regular contractions that are becoming stronger and closer together
Bloody show (mucus mixed with blood)
Rupture of membranes (breaking of water)
If the nurse suspects that the client is in labor, she should notify the healthcare provider immediately.
Another condition that can occur at term is preeclampsia. Preeclampsia is a serious condition that can cause high
blood pressure, protein in the urine, and swelling in the face, hands, and feet. If the nurse suspects that the client has
preeclampsia, she should monitor the client's blood pressure, protein levels in the urine, and weight. She should also
notify the healthcare provider immediately.
In addition to monitoring for these specific conditions, the nurse should also perform a general assessment of the
client's health. This includes taking the client's vital signs, checking her abdomen for fetal movement, and listening to
the baby's heartbeat.
By monitoring the client for signs and symptoms of these conditions, the nurse can help to ensure a safe and healthy
delivery for both the mother and the baby.
Therefore, the two most important actions the nurse should take are:
Monitor the client for signs and symptoms of labor and preeclampsia.
Perform a general assessment of the client's health.
The two most important parameters the nurse should monitor are:
Contraction frequency and intensity
Fetal heart rate
By following these steps, the nurse can provide the best possible care for the client and her baby.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Preparing the client for an emergency cesarean birth is an important step, but it is not the first action the nurse should take.
The immediate priority is to relieve pressure on the cord to prevent or alleviate cord compression.
Choice B rationale:
Covering the cord with a sterile, moist saline dressing is done to prevent drying of the cord and to maintain blood flow.
However, this is not the first action to take. The priority is to relieve cord compression by changing the client’s position.
Choice C rationale:
While it is important to explain to the client what is happening, this should not be the first action. The nurse’s priority is to
ensure the safety of the mother and baby, which involves immediate interventions to relieve cord compression.
Choice D rationale:
Placing the client in a knee-chest or Trendelenburg position is the first action the nurse should take. This position helps to
reduce pressure on the cord, which can improve blood flow to the fetus. It is a critical intervention that can prevent serious
complications such as fetal hypoxia.
Correct Answer is C
Explanation
Choice A rationale:
Stopping breastfeeding until the antibiotics are done is not a recommended practice. Most antibiotics are safe to use while
breastfeeding. Moreover, stopping breastfeeding can lead to engorgement.
Choice B rationale:
Applying cold compresses 20 minutes before each feeding is not a recommended practice. Cold compresses are usually
recommended after breastfeeding to help reduce swelling. Warm compresses or taking a warm shower before breastfeeding
can help increase milk flow and promote the letdown reflex.
Choice C rationale:
Feeding the baby every 2 hours is a good practice to prevent breast engorgement. Frequent feeding helps to empty the breasts,
which can prevent them from becoming overly full and engorged.
Choice D rationale:
Not wearing a bra during the daytime is not a recommended practice. Wearing a well-fitted bra can provide support and help
reduce discomfort associated with breast engorgement.
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