A nurse is assisting in the care of a client who is at 38 weeks of gestation.
What condition is the client most likely experiencing, what are 2 actions the nurse should take to address that
condition, and what are 2 parameters the nurse should monitor to assess the client’s progress?
The client is experiencing preterm labor.
The nurse should administer prescribed medication and encourage bed rest.
The nurse should monitor contraction frequency and fetal heart rate.
The Correct Answer is C
Choice C rationale:
Monitoring contraction frequency is essential to assess the progression of labor. Contractions are the tightening and relaxing of the uterine muscles that help to dilate the cervix and push the baby down the birth canal. The frequency of contractions is measured in minutes from the beginning of one contraction to the beginning of the next. As labor progresses, contractions become more frequent, regular, and intense. Monitoring contraction frequency helps the nurse to determine the stage of labor, assess the effectiveness of interventions, and identify any potential complications.
Monitoring fetal heart rate is crucial to assess the well-being of the baby during labor. The fetal heart rate is normally between 110 and 160 beats per minute. A normal fetal heart rate indicates that the baby is getting enough oxygen and is not in distress. Variations in the fetal heart rate, such as decelerations or tachycardia, can indicate potential problems and may require intervention.
Choice A rationale:
Preterm labor is defined as labor that begins before 37 weeks of gestation. The client in this scenario is at 38 weeks of gestation, which is considered term. Therefore, preterm labor is not the most likely condition.
Choice B rationale:
The administration of medication and bed rest may be appropriate interventions for preterm labor, but they are not the most appropriate interventions for a client in labor at 38 weeks of gestation. At this stage of pregnancy, labor is considered to be full-term, and interventions are focused on supporting the normal labor process and ensuring the safety of the mother and baby.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Heavy vaginal bleeding in late pregnancy, especially at 39 weeks of gestation, is a medical emergency that requires immediate
intervention.
It can be a sign of placental abruption, a serious condition in which the placenta separates from the uterine wall prematurely.
Placental abruption can lead to fetal distress and maternal hemorrhage, both of which can be life-threatening.
Cesarean birth is the quickest and safest way to deliver the baby in this situation.
It allows the healthcare team to control the bleeding and prevent further complications.
Delaying a cesarean birth can put the mother and baby at increased risk.
Choice B rationale:
Antibiotics are not indicated for heavy vaginal bleeding in late pregnancy.
They are used to treat infections, not bleeding.
There is no evidence to suggest that the client has an infection.
Choice C rationale:
Magnesium sulfate is a medication used to prevent seizures in women with preeclampsia.
It is not indicated for heavy vaginal bleeding.
There is no evidence to suggest that the client has preeclampsia.
Choice D rationale:
A cervical examination is not necessary in this situation.
The priority is to deliver the baby as quickly as possible.
A cervical examination would only delay the delivery.
Correct Answer is B
Explanation
Rationale for Choice A: Increase IV fluid rate
While hypotension is a potential complication of epidural anesthesia, increasing the IV fluid rate is not the first-line
intervention in this scenario. While fluid resuscitation may be necessary in some cases, it has the potential to further decrease
the client's blood pressure and exacerbate the situation. Additionally, the cause of the hypotension is not yet fully determined,
and increasing fluids without addressing the underlying cause could mask or worsen the problem.
Rationale for Choice B: Place the client in a lateral position
Supine hypotension, a sudden drop in blood pressure upon assuming a supine position, is a common complication of epidural
anesthesia. This occurs due to aortocaval compression, where the enlarged uterus compresses the major blood vessels
supplying the lower body and returning blood to the heart. Placing the client in a lateral position, preferably tilted slightly to
the left, alleviates this compression, allowing blood to flow more freely and improving blood pressure. This intervention is
simple, non-invasive, and has the potential to quickly resolve the hypotension without further interventions.
Rationale for Choice C: Notify the provider
While notifying the provider is certainly warranted in this situation, it should not be the first action taken. The client's vital
signs indicate a potentially serious situation requiring immediate intervention. Delaying action while waiting for the provider
could have negative consequences for both the client and the fetus. Therefore, placing the client in a lateral position should be
the immediate priority followed by notifying the provider to discuss further management.
Rationale for Choice D: Elevate the legs
Elevating the legs is a standard intervention for managing orthostatic hypotension, which is characterized by dizziness or
lightheadedness upon standing. However, in this case, the client is already supine and experiencing supine hypotension, not
orthostatic hypotension. Elevating the legs would not address the aortocaval compression and may even worsen the venous
return, further decreasing blood pressure.
Additional Notes:
Other interventions that may be considered depending on the client's response and provider's assessment include
administering vasopressors to increase blood pressure and administering oxygen to improve fetal oxygenation.
Continuous monitoring of the client's vital signs and fetal heart rate is crucial to assess the effectiveness of interventions and
identify any further deterioration.
Prompt communication with the provider is essential to ensure timely and appropriate management of the situation.
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.