A primigravida at 40 weeks of gestation is having erratic uterine contractions every 5 to 10 minutes and states that they are very painful.
Her cervix is dilated 2 cm and has not changed in 3 hours.
The woman is crying and wants an epidural.
What is the likely status of this woman's labor?
She is exhibiting hypotonic uterine dysfunction.
She is experiencing a normal latent stage.
She is exhibiting hypertonic uterine dysfunction.
She is experiencing precipitous labor.
The Correct Answer is B
Choice A rationale
Hypotonic uterine dysfunction typically occurs in the active phase of labor (after 4 cm cervical dilation) and is characterized by weak, infrequent, and ineffective contractions that do not lead to cervical change. The client in the latent phase with slow cervical change is not yet in the active phase.
Choice B rationale
The latent phase of the first stage of labor is characterized by irregular, mild to moderate contractions that cause slow, gradual cervical dilation and effacement. It can be lengthy, especially in primigravidas, and the discomfort can be significant. A cervical dilation of 2 cm with no change in 3 hours in the presence of painful, erratic contractions every 5 to 10 minutes aligns with a normal latent phase.
Choice C rationale
Hypertonic uterine dysfunction usually occurs in the latent phase and is characterized by frequent, uncoordinated, and strong contractions that are ineffective in causing cervical dilation or effacement. While the contractions are painful, they are not described as excessively strong or uncoordinated, and the client is in the expected early stage of labor.
Choice D rationale
Precipitous labor is a very rapid labor and delivery, typically lasting less than 3 hours from the onset of regular contractions to expulsion of the fetus. The client's labor is progressing slowly, with minimal cervical change over 3 hours, which is the opposite of precipitous labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
When the fetal heart tones are heard loudest in the upper right abdominal quadrant above the umbilicus, it suggests that the fetal back, which transmits sound most clearly, is located in that area. In a breech presentation, the fetal buttocks or feet are in the lower uterine segment, and the head is in the upper portion of the uterus. Therefore, the fetal heart sounds would be best auscultated in the upper abdomen.
Choice B rationale
In the left occiput anterior (LOA) position, the fetal occiput is in the left anterior quadrant of the maternal pelvis. The fetal heart tones are typically heard loudest in the lower left quadrant of the maternal abdomen because the fetal back is usually anterior and slightly to the left.
Choice C rationale
Polyhydramnios is an excessive amount of amniotic fluid. While it can sometimes make it more difficult to auscultate fetal heart tones clearly due to increased fluid volume, it does not directly correlate with the location where the heart tones are heard loudest. The position of the fetus is the primary determinant of the auscultation location.
Choice D rationale
In the right occiput posterior (ROP) position, the fetal occiput is in the right posterior quadrant of the maternal pelvis. The fetal heart tones would typically be heard loudest in the lower right quadrant of the maternal abdomen, as the fetal back would be positioned posteriorly and to the right.
Correct Answer is A
Explanation
Choice A rationale
Methergine (methylergonovine) is an oxytocic medication that causes vasoconstriction and increases blood pressure. It is contraindicated in clients with hypertension. Therefore, assessing the client's blood pressure before administration is crucial to ensure safety. Normal adult blood pressure is typically less than 120/80 mmHg.
Choice B rationale
Assessing uterine tone is important in managing postpartum hemorrhage, as a boggy uterus contributes to bleeding. However, before administering a medication that affects blood pressure, the blood pressure itself is the priority assessment due to the contraindications of Methergine in hypertensive clients.
Choice C rationale
Deep tendon reflexes are assessed in the postpartum period, particularly for clients with preeclampsia who are at risk for magnesium sulfate toxicity. While important, it is not the priority assessment before administering Methergine, which has a direct impact on blood pressure.
Choice D rationale
Assessing the amount of lochia is essential for monitoring postpartum bleeding. However, before administering Methergine, which can significantly increase blood pressure, ensuring the client does not have a contraindication related to hypertension is the most critical immediate assessment. .
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