A nurse is caring for a client in active labor.
Admission Assessment.
0200:. Gravida 1, Para 0 at 39 weeks gestation.
Presents with.
contractions occurring every 5 to 6 min, 45 to 60 seconds.
duration.
Cervical examination 4 cm dilated, 50% effaced.
Admit.
to the labor and delivery unit.
Nurses' Notes.
0200:. Admitted to the labor and delivery unit, and reports pain as 7 on a scale.
of O to 10 with contractions.
Cervix 4 cm dilated, 50% effaced,with membranes intact.
0230:. The client reports increasing discomfort with contractions.
Cervix 5. cm dilated, 60% effaced, with membranes intact.
Contractions.
occurring every 5 min, 45 to 60 seconds duration.
0300:. Epidural anesthesia was initiated.
Cervix 7 cm dilated, 70% effaced,. with membranes intact.
Contractions occur every 4 to 5 min,60 seconds duration.
Vital Signs.
0200:. Temperature 36.9° C (98.4° F). Heart rate 86/min.
Respiratory rate 18/min.
BP 118/78 mm Hg. 0230:. Temperature 37° C (98.6° F). Heart rate 88/min.
Respiratory rate 20/min.
BP 120/80 mm Hg. 0300:. Temperature 37.1° C (98.8° F). Heart rate 90/min.
Respiratory rate 18/min.
BP 122/76 mm Hg. The nurse is assuming care for the client at 0305.
For each nursing action, click to specify if the nursing action is essential. contraindicated for the client.
Assess for urinary retention.
Encourage the client to turn from side to side.
Monitor for elevated temperature.
Inform the client to expect drowsiness.
Assist the client with ambulation.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
No explanation
Correct Answer is ["A","C"]
Explanation
The correct answers are Choices A and C.
Choice A rationale: Severe hypertension in pregnancy disrupts placental perfusion and vascular integrity, increasing risk of placental abruption due to premature separation and hemorrhage, threatening both maternal and fetal outcomes.
Choice B rationale: Cervical insufficiency is linked to structural weakness or trauma, not hypertension; it typically presents with painless dilation and is unrelated to elevated blood pressure or vascular compromise.
Choice C rationale: Hypertensive encephalopathy and preeclampsia can progress to eclampsia, marked by seizures. Elevated BP increases cerebral edema and excitability, triggering convulsions if unmanaged.
Choice D rationale: Hypoglycemia is not a direct consequence of hypertension; it’s more associated with insulin dysregulation, poor intake, or medication effects, not elevated blood pressure.
Choice E rationale: Heart failure may occur in chronic hypertension but is less acute than seizure or abruption risk in this context. No signs of fluid overload or cardiac decompensation are present in the vitals.
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