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 D
Explanation
A. Brownish vaginal discharge may indicate the presence of old blood or mucus and is not necessarily a cause for concern in the absence of other signs or symptoms.
B. Contractions occurring every 4 to 5 minutes are within the normal frequency range during the first stage of labor.
C. Pink mucoid vaginal discharge, also known as the "bloody show," is a common occurrence in early labor and is not typically a cause for immediate concern.
D. Contractions lasting 100 seconds are excessively long and are a cause for concern.
Prolonged contractions can lead to decreased uterine blood flow, impacting fetal oxygenation. Such prolonged contractions should be assessed and addressed promptly.
Correct Answer is A
Explanation
The correct answer is A. Assist the client to turn onto her side.
A. Assisting the client to turn onto her side is the correct intervention. This is because the client's blood pressure is low, and turning onto the side helps improve blood flow to the uterus, reducing the risk of supine hypotension.
B. Assisting the client to an upright position is not the priority in this case. The client is at risk for supine hypotension, and a lateral position is more appropriate.
C. Preparing for a cesarean birth is not indicated based solely on the blood pressure reading. Turning the client onto her side and monitoring the blood pressure response are appropriate initial actions.
D. Preparing for an immediate vaginal delivery is not indicated based solely on the blood pressure reading. The client's condition may improve with positional changes, and further assessment is needed.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.