A nurse is caring for a client who is at 40 weeks gestation and is lying supine while 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 an upright position.
Prepare for a cesarean birth.
Assist the client to turn onto her side.
Prepare for an immediate vaginal delivery.
The Correct Answer is C
Choice A: While an upright position is generally beneficial during labor to improve uterine contractions and fetal positioning, it is not the priority in this situation of hypotension.
Choice B: Preparing for a cesarean birth is not indicated solely based on the blood pressure reading. Cesarean birth should be considered based on the overall assessment and clinical condition of the client and baby.
Choice C: The client's blood pressure reading of 82/52 mm Hg indicates hypotension. In this situation, the nurse should assist the client in turning onto her side to relieve pressure on the vena cava and improve blood flow to the placenta and the baby. Lying supine can compress the vena cava, leading to decreased venous return and reduced cardiac output, which may negatively affect fetal oxygenation and maternal wellbeing.
Choice D: Preparing for an immediate vaginal delivery is not the priority at this moment. The nurse should first address the hypotension and improve maternal blood flow before proceeding with delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: Engaging in moderate physical activity during pregnancy, such as jogging, is generally safe and beneficial for pregnant women who have uncomplicated pregnancies. Staying hydrated, avoiding excessive exertion, and preventing overheating are important considerations during exercise.
B: The use of saunas and hot tubs during pregnancy is generally not recommended at any trimester, as they can cause hyperthermia and pose risks to the developing fetus.
C: Limiting exercise to only stretching on a mat is not appropriate during pregnancy. Regular physical activity is generally encouraged, provided there are no specific contraindications or complications.
D: Completely avoiding exercise during pregnancy is not recommended, as moderate and appropriate physical activity can have various benefits for both the mother and the baby.
Correct Answer is C
Explanation
A: Administering glucocorticoids intramuscularly is indicated for enhancing fetal lung maturity in cases of anticipated preterm birth. However, the client is at 38 weeks of gestation, which is not considered preterm, and the elevated temperature is the main concern.
B: Preparing the client for an emergency cesarean section based solely on an elevated temperature is not an appropriate action. There may be other factors contributing to the temperature elevation, and further assessment is needed.
C: An elevated temperature during pregnancy can indicate infection, which is a concern when the client's membranes have ruptured (premature rupture of membranes or PROM). Before any
interventions are initiated, the nurse should assess the odor of the amniotic fluid as it can provide important information about possible infection. If the amniotic fluid has a foul odor or appears
cloudy, it may indicate infection and require prompt medical attention.
D: Rechecking the client's temperature in 4 hours is not the appropriate immediate action when an elevated temperature is observed, especially in a pregnant woman.
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