A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min. maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
Have the client void.
Position the client with one hip elevated.
Ask the client if she needs pain medication.
Notify the provider of the findings.
The Correct Answer is B
The correct answer is B. Position the client with one hip elevated.
A. Having the client void is a good practice, but it is not the priority action in this situation. The client's vital signs suggest a potential issue with uteroplacental perfusion, and repositioning the client should be the priority.
B. Positioning the client with one hip elevated is the priority action.
The vital signs, specifically the low blood pressure, may be indicative of aortocaval compression (supine hypotension). Elevating one hip helps alleviate this compression, improving blood flow and potentially addressing the decreased blood pressure.
C. Asking the client if she needs pain medication is important, but repositioning the client takes precedence due to the potential issue with blood pressure and uteroplacental perfusion.
D. Notifying the provider is important, but repositioning the client to improve blood flow should be done first. The provider may be notified afterward based on the client's response and ongoing assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. Position the client with one hip elevated.
A. Having the client void is a good practice, but it is not the priority action in this situation. The client's vital signs suggest a potential issue with uteroplacental perfusion, and repositioning the client should be the priority.
B. Positioning the client with one hip elevated is the priority action.
The vital signs, specifically the low blood pressure, may be indicative of aortocaval compression (supine hypotension). Elevating one hip helps alleviate this compression, improving blood flow and potentially addressing the decreased blood pressure.
C. Asking the client if she needs pain medication is important, but repositioning the client takes precedence due to the potential issue with blood pressure and uteroplacental perfusion.
D. Notifying the provider is important, but repositioning the client to improve blood flow should be done first. The provider may be notified afterward based on the client's response and ongoing assessment.
Correct Answer is D
Explanation
The correct answer is D.
A. Insert the syringe tip before compressing the bulb: This is incorrect. The nurse should compress the bulb syringe first, then gently insert the tip into the newborn's nose, and then release the bulb to create suction for removing the mucus.
B.The client should suction the mouth first then the nares.
C. Insert the tip of the syringe into the center of the newborn's mouth: This is incorrect. The tip of the bulb syringe should be inserted into the side of the baby's mouth to avoid causing discomfort or stimulating the gag reflex.
D. When the newborn's cry may sound clear due to vocalization, but this may indicate that the airways are clear of secretions.
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