A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?
Observe for the presence of a nuchal cord.
Prepare to administer oxytocin.
Observe for crowning.
Apply fundal pressure.
The Correct Answer is C
A. Observe for the presence of a nuchal cord: While this is important, it is not specifically related to the finding of the fetal head at a certain station.
B. Prepare to administer oxytocin: Oxytocin is a hormone used to induce or augment labor, but there is no indication for its use based solely on the fetal head station.
C. Observe for crowning: The fetal head at 3+ station indicates significant descent, and crowning may occur soon. Crowning is the appearance of the fetal head at the vaginal opening and indicates that delivery is imminent.
D. Apply fundal pressure: Fundal pressure is not appropriate at this stage of labor and could cause harm.
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Correct Answer is D
Explanation
A. Immediately report the situation to the client's provider and prepare the client for induction of labor.This option is premature. The absence of fetal movement for 15 minutes during a nonstress test does not immediately indicate a need for induction of labor. Other less invasive interventions should be attempted first to stimulate fetal movement.
B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. While movement can sometimes stimulate fetal activity, removing the monitoring unit is not advisable during a nonstress test. Continuous monitoring is essential to accurately assess the fetal heart rate and movement.
C. Turn the client onto her left side.This position can improve uteroplacental blood flow and may help stimulate fetal movement. However, it is not the most effective initial intervention compared to offering a snack, which can provide a quicker response.
D. Offer the client a snack of orange juice and crackers.This is the correct intervention. The sugar in the orange juice can provide a quick source of energy to the fetus, potentially stimulating movement. Additionally, the act of eating can sometimes prompt fetal activity.
Correct Answer is C
Explanation
A) Vomiting: Vomiting is not a common complication of epidural anesthesia. Nausea can occur but is not directly related to the epidural block itself.
B) Tachycardia: Tachycardia is not a common complication of epidural anesthesia. It may occur due to other factors, but it is not directly associated with the epidural block.
C) Hypotension: Hypotension (low blood pressure) is a common complication of epidural anesthesia. The epidural can cause vasodilation, leading to a drop in blood pressure. It is essential to monitor the client's blood pressure and intervene promptly if hypotension occurs.
D) Respiratory depression: Respiratory depression is not a typical complication of epidural anesthesia. Epidural anesthesia mainly affects the lower part of the body and does not usually cause significant respiratory effects.
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