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 C
Explanation
Choice A Reason:
Hemoglobin (Hgb) of 20 g/dL is elevated, but this can be a normal finding in a newborn and does not necessarily require immediate intervention.
Choice B Reason:
Total bilirubin of 5 mg/dL is within the normal range for a 24-hour-old newborn.
Choice C Reason:
Blood glucose 30 mg/dL. A blood glucose level of 30 mg/dL is significantly lower than the normal range for a newborn. Hypoglycemia in a newborn can lead to neurologic complications, so it is important to report this result promptly for further evaluation and intervention.
Choice D Reason:
White blood cell (WBC) count of 20,000/mm³ is within the expected range for a newborn and is not a cause for immediate concern. Newborns often have higher WBC counts shortly after birth.
Correct Answer is C
Explanation
Choice A Reason:
Drinking the glucose solution 2 hours prior to the test is not standard for a 1-hour GTT. Instead, the glucose solution is usually consumed within a short timeframe, such as 5 minutes, and the blood is drawn 1 hour afterward.
Choice B Reason:
Limiting carbohydrate intake for 3 days prior to the test is not a requirement for a 1-hour GTT. However, it may be advised for a longer fasting period or a different type of glucose tolerance test.
Choice C Reason:
C. “A blood glucose of 130 to 140 is considered a positive screening result.”
In the 1-hour glucose tolerance test during pregnancy, a blood glucose level of135 mg/dL or higheris considered a positive screening result. If this threshold is met, further testing (such as the 3-hour glucose tolerance test) is recommended to confirm or rule out gestational diabetes.
.
Choice D Reason:
Fasting for 12 hours prior to the test is inappropriate. For a 1-hour GTT, the client is not typically required to fast.
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