The nurse is managing care of a primigravida at full term who is in the active phase of labor.
What should be included in developing the plan of care for this client?

Supine positioning on back if it is comfortable.

Anesthesia/pain level assessment every 30 minutes.

Vaginal bleeding and fundus of the uterus after delivery of the placenta.

Oxygen saturation monitoring every half hour.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Supine positioning can compress the vena cava, leading to decreased venous return, reduced cardiac output, and potential maternal hypotension, which can compromise fetal oxygenation. Alternative positions like lateral or semi-recumbent are generally preferred during labor to optimize blood flow.

Choice B rationale

Assessing anesthesia or pain level every 30 minutes is crucial in the active phase of labor to evaluate the effectiveness of pain management interventions and the client's comfort. This frequent monitoring allows for timely adjustments to the pain management plan based on the client's subjective experience and physiological responses.

Choice C rationale

While assessing vaginal bleeding and the fundus is important in the postpartum period to monitor for uterine involution and hemorrhage, it is not the priority during the active phase of labor. The focus during active labor is on maternal and fetal well-being during the labor process itself.

Choice D rationale

Continuous or intermittent oxygen saturation monitoring may be indicated based on the client's condition and fetal heart rate patterns, but it is not a routine assessment every half hour for all clients in active labor. It is typically reserved for situations of suspected maternal hypoxemia or fetal distress.

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Correct Answer is ["A","B"]

Explanation

Choice A rationale

Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. Symptoms can include unilateral abdominal pain, light to heavy vaginal bleeding, and a positive pregnancy test. An ectopic pregnancy is a serious condition requiring prompt medical attention.

Choice B rationale

Molar pregnancy, also known as gestational trophoblastic disease, is characterized by abnormal growth of trophoblasts, the cells that normally develop into the placenta. It can present with symptoms such as vaginal bleeding (ranging from spotting to heavy bleeding), pelvic pain or pressure, and a uterus that may be larger than expected for the gestational age. The absence of a fetal heartbeat and elevated hCG levels are also characteristic.

A. Increase in blood pressure. B. Report of absent breast pain. C. Increase in lochia. D. Fundus firm to palpation.

Correct Answer is D

Explanation

Choice A rationale

Methylergonovine is an oxytocic medication that stimulates smooth muscle contraction of the uterus. While it can cause vasoconstriction and potentially lead to an increase in blood pressure, this is a potential side effect, not the intended therapeutic effect indicating the medication's effectiveness in the postpartum period. The primary goal is uterine contraction to control postpartum bleeding.

Choice B rationale

Breast pain is related to engorgement and milk production, not directly influenced by methylergonovine's action on the uterus. The medication's effectiveness is assessed by its impact on uterine tone and bleeding, not breast comfort. Therefore, the absence of breast pain does not indicate that the methylergonovine has been effective.

Choice C rationale

Methylergonovine is given to decrease postpartum bleeding by promoting uterine contraction, which helps to compress the blood vessels at the placental site. An increase in lochia (postpartum vaginal discharge) would suggest that the medication is not effective in achieving its intended therapeutic outcome of reducing hemorrhage.

Choice D rationale

Methylergonovine's primary therapeutic effect in the postpartum period is to stimulate uterine smooth muscle contraction, leading to a firm fundus. A firm fundus indicates that the uterus is contracting effectively, which helps to compress blood vessels at the placental site and control postpartum bleeding. This is the desired outcome of methylergonovine administration.

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The nurse is managing care of a primigravida at full term who is in the active phase of labor.What should be included in developing the plan of care for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is being admitted to the labor and delivery unit.Client reports mild abdominal pain and light vaginal bleeding.Reports last menstrual period was 11 weeks ago.

Correct Answer is ["A","B"]

Explanation

A nurse is caring for a client who is postpartum and received methylergonovine.Which of the following findings indicates that the medication was effective?

Correct Answer is D

Explanation

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A nurse is assessing a client who is 8 hours postpartum.Where should the nurse expect to find the fundus?

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The nurse is managing care of a primigravida at full term who is in the active phase of labor.
What should be included in developing the plan of care for this client?