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
A. Contractions that last 45 seconds each with a 3-minute rest between contractions are less common. Typically, contractions last around 60 seconds during active labor.
B. Contractions that last for 60 seconds each with a 3-min rest between contractions is the expected pattern.
During active labor, contractions are commonly around 60 seconds in duration, and they occur approximately every 4-5 minutes.
C. Contractions that last for 60 seconds each with a 4-min rest between contractions are not consistent with the usual pattern of contractions in active labor. A 4-minute rest between contractions would be an extended interval.
D. A contraction that lasts for 4 minutes followed by a period of relaxation is not typical and may indicate a problem. Normal contractions usually last around 60 seconds or less.
Correct Answer is A
Explanation
The correct answer is A. Contractions lasting longer than 90 seconds.
A. Contractions lasting longer than 90 seconds can be indicative of a prolonged contraction, which may affect uteroplacental perfusion and fetal oxygenation. This is a concern and should be reported to the provider.
B. Contractions occurring every 3 to 5 minutes are within the normal frequency range during the active phase of the first stage of labor.
C. The client reporting feeling contractions in the lower back is a common description of back labor, which may occur due to the position of the baby. It is not necessarily a cause for immediate concern unless it is associated with other issues.
D. Contractions being strong in intensity is expected during the active phase of labor. Strong contractions are necessary for cervical dilation and the progression of labor.
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