A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
Assist the client to turn onto her side.
Prepare for an immediate vaginal delivery.
Prepare for a cesarean birth.
Assist the client to an upright position.
The Correct Answer is A
Assist the client to turn onto her side. This is the correct answer because turning the client onto her side can improve blood flow to the placenta and increase fetal oxygenation. Hypotension is a common cause of decreased uteroplacental perfusion, which can lead to fetal distress and late decelerations on the fetal monitor. The nurse should also administer oxygen, increase IV fluids, and notify the provider. • Choice B reason:
Prepare for an immediate vaginal delivery. This is not the correct answer because there is no indication that the client is ready for delivery. The client has 6 cm of cervical dilation, which means she is still in the active phase of labor. The second stage of labor begins when the cervix is fully dilated (10 cm) and ends with delivery of the baby. Preparing for an immediate vaginal delivery would not address the cause of hypotension or improve fetal oxygenation. • Choice C reason:
Prepare for a cesarean birth. This is not the correct answer because there is no indication that the client needs a cesarean birth. A cesarean birth may be indicated if there are signs of fetal compromise, such as severe variable or late decelerations, or maternal complications, such as placenta previa or cord prolapse. However, these conditions are not present in this scenario. Preparing for a cesarean birth would not address the cause of hypotension or improve fetal oxygenation. • Choice D reason:
Assist the client to an upright position. This is not the correct answer because placing the client in an upright position can worsen hypotension and decrease uteroplacental perfusion. An upright position can increase pressure on the inferior vena cava and reduce venous return to the heart. This can lower cardiac output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
If the client reports frequent uterine contractions , it is not indicative of a distended bladder. Postpartum uterine contractions are normal and necessary to help the uterus return to its pre-pregnancy size.
Choice B reason:
The fundus (the top portion of the uterus being palpable to the right of the midline suggests a distended bladder. A full bladder can displace the uterus, causing the fundus to deviate from the midline.
Choice C reason:
Having less than 2.5 cm of rubra lochia on a perineal pad is related to the amount of vaginal discharge after birth and does not provide information about bladder distention.
Choice D reason:
The client's report of increased thirst may indicate dehydration or the body's response to fluid loss during childbirth but is not directly related to bladder distention.
Correct Answer is B
Explanation
Choice A reason:
Inspecting if the urethral opening appears circular. This is a correct action for the nurse to do, as it helps to identify any abnormalities in the urethral opening, such as hypospadias or epispadias, which are congenital defects where the opening is located on the underside or the top of the penis, respectively. • Choice B reason:
Retracting the foreskin over the glans to assess for secretions. This is an incorrect action for the nurse to avoid, as it can cause pain, bleeding, and infection in the newborn. The foreskin is usually adhered to the glans in newborns and should not be forcibly retracted. It will gradually loosen over time and can be retracted by the child himself when he is older. •
Choice C reason:
Palpating if testes are descended into the scrotal sac. This is a correct action for the nurse to do, as it helps to detect any undescended testes, which are more common in preterm infants and can increase the risk of infertility and testicular cancer later in life. • Choice D reason:
Inspecting the genital area for irritated skin. This is a correct action for the nurse to do, as it helps to identify any signs of diaper rash, fungal infection, or allergic reaction in the newborn's skin.
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