A nurse is assisting with the care of a client who is in the latent phase of labor and just had an amniotomy. Which of the following findings indicates that the fetus is at risk?

Recurrent variable deceleration of the FHR

Uterine contractions every 6 min

Uterine contractions lasting 30 to 45 seconds

Moderate variability of the FHR

Answer and Explanation

The Correct Answer is A

A.   Recurrent variable decelerations of the fetal heart rate (FHR) are concerning and can indicate fetal distress.
B.   Uterine contractions every 6 minutes may not provide effective progress in labor, but it is not indicative of fetal distress.
C.   Uterine contractions lasting 30 to 45 seconds are within the normal range for labor.
D.   Moderate variability of the FHR is a reassuring sign and indicates that the fetus is tolerating labor well.

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Correct Answer is C

Explanation

A. Increasing systolic blood pressure: Carboprost is not indicated for increasing systolic blood pressure. If a client's blood pressure is elevated, it may require monitoring and, if necessary, treatment with antihypertensive medication.
B. Breast engorgement: Carboprost is not used to address breast engorgement. Breast engorgement is typically managed with measures like warm compresses, breastfeeding, and potentially pain relievers or other interventions.
C. Pooling of blood beneath the buttocks: This is a concerning sign of potential postpartum hemorrhage. Carboprost is indicated in situations where there is excessive bleeding or inadequate uterine contractions to help control bleeding and prevent further complications.
D. Bladder distention: Carboprost is not used to address bladder distention. Bladder distention may require measures such as catheterization to empty the bladder andalleviate discomfort.

A. Provide the client with ice packs for her breasts. B. Advise the client to avoid using a breast pump. C. Have the client apply purified lanolin to her breasts. D. Encourage the client to wear a loose-fitting bra.

Correct Answer is A

Explanation

A. Ice packs can help reduce swelling and inflammation associated with engorgement by constricting blood vessels and reducing blood flow to the area, which can alleviate pain and discomfort.
B. Avoiding the use of a breast pump may exacerbate engorgement. It is appropriate to use a pump if needed for comfort or to facilitate breastfeeding.
C. While purified lanolin can help soothe sore nipples, it does not address the inflammation and swelling of engorgement.
D. A well-fitting, supportive bra is important, but it should not be too tight. It should provide adequate support without constricting the breasts.

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A nurse is assisting with the care of a client who is in the latent phase of labor and just had an amniotomy. Which of the following findings indicates that the fetus is at risk?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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