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: Quickening, which refers to the sensation of the baby moving in the womb, is considered a presumptive sign of pregnancy. It is called "presumptive" because it is subjective and can be attributed to other causes, such as gas or gastrointestinal movements.
B: Positive signs of pregnancy are those that are attributed only to the presence of a fetus, such as fetal heartbeat or visualization on ultrasound. Feeling the baby move (quickening) is not specific enough to confirm pregnancy on its own.
C: Probable signs of pregnancy are more objective and can be detected by a healthcare provider, such as a positive pregnancy test or ballottement (rebounding of the fetus against the examiner's fingers). Feeling the baby move is not a probable sign as it is subjective and can be attributed to other factors.
D: "Potential sign of pregnancy" is not a recognized classification in pregnancy signs.
Correct Answer is C
Explanation
The correct answer is: c. 42022
Choice A: 40122
Reason: This choice is incorrect because it indicates 4 pregnancies (correct), 0 term births (correct), 1 preterm birth (correct), 2 abortions (correct), but 2 living children (incorrect). The client has 2 living children, which is correct, but the term and preterm counts are not accurate.
Choice B: 20020
Reason: This choice is incorrect because it indicates 2 pregnancies (incorrect), 0 term births (correct), 0 preterm births (incorrect), 2 abortions (correct), and 0 living children (incorrect). The client has had 4 pregnancies, 1 preterm birth, and 2 living children.
Choice C: 42022
Reason: This choice is correct. It indicates 4 pregnancies (current pregnancy, elective abortion, twins, spontaneous abortion), 0 term births, 2 preterm births (twins at 36 weeks), 2 abortions (elective at 9 weeks, spontaneous at 15 weeks), and 2 living children (twins).
Choice D:
The GTPAL system is used to assess a client's obstetric history:
- G (Gravida): The total number of pregnancies, including the current one.
- T (Term births): The number of pregnancies carried to at least 37 weeks.
- P (Preterm births): The number of pregnancies delivered between 20 and 36 weeks, 6 days.
- A (Abortions): The number of pregnancies ending before 20 weeks (spontaneous or elective).
- L (Living children): The number of children currently alive.
For this client:
G (Gravida): 4 (one elective abortion, one twin pregnancy, one spontaneous abortion, and the current pregnancy).
- T (Term births): 0 (the twin pregnancy was delivered at 36 weeks, which is preterm).
- P (Preterm births): 1 (twins delivered at 36 weeks count as one preterm birth).
- A (Abortions): 2 (one elective abortion at 9 weeks, one spontaneous abortion at 15 weeks).
- L (Living children): 2 (the twins).
Thus, the GTPAL for this client is 4-0-1-2-2.
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