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.

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Correct Answer is B

Explanation

A. Assist in initiating IV access and administering IV fluid bolus: While IV fluids may be needed, the priority in this case is to address the umbilical cord prolapse, which poses an immediate risk to the baby.

B. Call for assistance immediately: Cord prolapse is an obstetric emergency that requires immediate assistance to prevent fetal hypoxia. Rapid response is crucial to save the baby.

C. Apply finger pressure to the presenting part: Although applying pressure to relieve compression on the cord is necessary, the first action should be to summon help to manage the emergency.

D. Administer oxygen at 10 L/min via a nonrebreather: Oxygen is important to improve maternal and fetal oxygenation, but calling for help is the immediate priority in this life-threatening situation.

A. Not satisfied with the nonpharmacological comfort measures B. active phase of labor C. Going to require more pain medication D. Going to have a long labor

Correct Answer is B

Explanation

A. Not satisfied with the nonpharmacological comfort measures. This describes dissatisfaction with pain management but does not specifically indicate a change in labor phase.

B. Active phase of labor. Nausea, irritability, and feelings of helplessness are classic signs of transitioning from the latent phase to the active phase of labor, when contractions become stronger and more intense.

C. Going to require more pain medication: Although the patient may need additional pain relief, the question is asking about labor progression, not pain management.

D. Going to have a long labor. Irritability and nausea are signs of labor progression, not necessarily an indicator of a long labor.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client in active labor. The nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?

Correct Answer is B

Explanation

A patient in the latent phase of labor begins to experience nausea, feelings of helplessness and has become very irritable. The nurse suspects that the patient is now in the

Correct Answer is B

Explanation

A nurse is assisting in the care of a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

A laboring patient reports to the nurse that "I think my water just broke!" The first action the nurse should take is:

A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and the fetal heart recording is 140/min. Which of the following actions should the nurse take first?

The nurse is preparing to assist the nurse midwife with an amnioinfusion. The patient asks, "Why do I need this?" The best response by the nurse is:

What is measured from the beginning of one contraction to the beginning of the next contraction?

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

Leopold's maneuvers are performed to:

What stage of labor ends with the physiologic stabilization of the mother?