A nurse on a labor and delivery unit is assisting in the care of a client who is at 39 weeks of gestation and is in the first stage of labor.

Exhibits

Complete the diagram by dragging from the choices below to specify what complication the client is most likely experiencing, 2 actions the nurse should take to address that complication, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Complication:

Variable Fetal Heart Rate Decelerations: Variable decelerations are typically associated with cord compression, which may occur during labor, especially with oligohydramnios (low amniotic fluid). The fetal heart rate drops to 100 bpm with contractions but recovers within 30 seconds, fitting the description of variable decelerations. Since amniotic fluid cushions the umbilical cord, a reduction in fluid can increase the likelihood of cord compression.

Actions to Take:

Turn client to left side: Repositioning the client to the left lateral position can relieve pressure on the umbilical cord, improve blood flow to the placenta, and reduce the occurrence of variable decelerations.
Initiate amnioinfusion: An amnioinfusion is a procedure where a sterile fluid is introduced into the uterus to increase the amount of amniotic fluid, reducing cord compression and improving fetal oxygenation. This can help alleviate variable decelerations caused by oligohydramnios.

Parameters to Monitor:

Fetal Heart Rate Baseline: Monitoring the fetal heart rate baseline is essential to assess if the decelerations are improving after interventions, ensuring the fetus is not in distress and maintaining an appropriate heart rate (120–160 bpm).
Uterine Contraction Frequency: Monitoring the frequency of contractions is important, especially if an amnioinfusion is performed, to ensure contractions are not becoming too frequent or too intense, which could further compromise fetal oxygenation and lead to distress.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Epidural Anesthesia. Epidural anesthesia involves injecting a local anesthetic into the epidural space, blocking pain signals from the lower body to the brain. It is commonly administered when the cervix is at least 4 cm dilated in active labor.

B. Local anesthesia. Local anesthesia numbs a specific, smaller area of the body and is typically used for procedures such as episiotomies or repairs, not for labor pain relief.

C. Pudendal block. A pudendal block is an injection that numbs the perineal area but does not block pain from contractions. It is used for pain relief during the second stage of labor or for episiotomies.

D. General anesthesia. General anesthesia affects the entire body and is rarely used in labor unless there is an emergency cesarean section when regional anesthesia is not possible.

A. Apply palms of both hands to one side of uterus. B. Stand facing client's feet with fingertips outlining cephalic prominence. C. Palpate the fundus of the uterus. D. Perform deep palpation of the uterus

Correct Answer is C

Explanation

A. Apply palms of both hands to one side of the uterus: This step helps identify the fetal position (whether the baby is facing left or right), not the fetal lie.

B. Stand facing the client's feet with fingertips outlining cephalic prominence. This maneuver helps determine fetal engagement, not fetal lie.

C. Palpate the fundus of the uterus. The fetal lie refers to whether the fetus is positioned longitudinally or transversely, and this is assessed by palpating the fundus to feel which part of the fetus is located there (e.g., head or buttocks).

D. Perform deep palpation of the uterus. Deep palpation helps identify the presenting part (what part of the fetus is entering the pelvis), not fetal lie.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An injection of local anesthetic drug into epidural space, which blocks transmission of pain impulses to brain and is given when cervix is in active labor at least 4cm dilated is called what?

Correct Answer is A

Explanation

A nurse is assisting with performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?

What is the most common cause of early decelerations in fetal heart rate?

A nurse is preparing to administer indomethacin 50 mg PO. Available is indomethacin oral suspension 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

What is considered non-pharmacological pain management from the list below? (please select all that apply)

A nurse is caring for a client who is at 28 weeks of gestation and has received terbutaline. Which of the following findings should the nurse expect?

A nurse is reviewing true labor vs false labor with a pregnant client. What statement by the client indicates teaching has been effective?

A nurse is reinforcing teaching about signs preceding the onset of labor with a client who is at 39 weeks of gestation. Which of the following statements should the nurse include?