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A nurse is caring for a client at 39 weeks gestation

Exhibits
Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again.

Vital Signs

1130

Oral temperature 38.3 C (101 F )

Heart rate 98min

Respiratory rate 18/min

Blood pressure 112/59 mm Hg 

Oxygen saturation 98% on room air

Nurses Notes

1130

Client states, ‘I think my water broke. The pad under me is soaked’. Clear fluid noted on pad. Nitrazine positive. Uterine contractions every 3 mins moderate to palpation. Fetal heart rate is 140/min.

Diagnostic Results

1200

HGB 10 g/dl (greater than 11 g/dl)

HCT 34% (greater that 33%)

WBC 22,000 ( 5,000 – 11,000)

A.

Oral temperature 38.3 C (101 F )

B.

HGB 10 g/dl (greater than 11 g/dl)

C.

Heart rate 98min

D.

Blood pressure 110/60 mm Hg

E.

Uterine contractions every 3 mins moderate to palpation

Answer and Explanation

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

  • Oral temperature 38.3°C (101°F)
    Elevated temperature indicates maternal fever, which could suggest infection such as chorioamnionitis, especially concerning with ruptured membranes.
  • HGB 10 g/dL (normal > 11 g/dL)
    Low hemoglobin indicates anemia, which could compromise oxygen delivery to the fetus and affect maternal health during labor.

Explanation for non-highlighted findings:

  • Heart rate 98/min: Slightly elevated but within normal range for labor.
  • Blood pressure 112/59 mm Hg: Normal blood pressure for pregnancy.
  • Uterine contractions every 3 mins moderate to palpation: Normal pattern for active labor.


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Related Questions

Correct Answer is A

Explanation

A. Administering methylergonovine (Methergine) intramuscularly is appropriate for treating postpartum hemorrhage, as it stimulates uterine contractions to help control bleeding.
B. The knee-chest position is not indicated for postpartum hemorrhage and does not address the underlying cause.
C. Oxygen may be necessary if the client is unstable, but 2 L/min via nasal cannula is not the primary intervention and may not be sufficient in a critical situation.
D. Dextrose water is not appropriate for fluid resuscitation during hemorrhage; isotonic fluids like normal saline or lactated Ringer’s are preferred to restore volume.

Correct Answer is B

Explanation

A. Urinary frequency is common in pregnancy but does not indicate labor progression.
B. Increased blood-tinged vaginal mucus (bloody show) indicates cervical dilation and labor progression.
C. Station is measured in centimeters but ranges from -3 to +3 relative to the ischial spines, so "3 cm" station is unclear and likely incorrect terminology.
D. Contractions easing with walking suggest false labor rather than progression.

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