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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A rationale
Immediately postpartum, the fundus is typically palpable. It gradually descends into the pelvic cavity over the following days.
Choice B rationale
By 6 to 12 hours postpartum, the fundus is usually located at the level of the umbilicus or slightly below it. It descends approximately one fingerbreadth (1 cm) per day.
Choice C rationale
In the immediate postpartum period, within the first few hours after delivery, the nurse should expect to find the fundus at the level of the umbilicus. This indicates that the uterus is contracting to control bleeding at the placental site.
Choice D rationale
Immediately after delivery, the fundus is typically higher than the symphysis pubis. It descends into the abdomen as the uterus contracts and the placental site begins to heal. .
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