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The nurse reviews the history and physical and nurses' notes to determine risk factors for this client.
Which potential issue(s) place the client at risk? Select all that apply.

Gravida 4: para 3.

Fetal heart rate 136 to 142 beats/minute.

Variable decelerations to 120 beats/minute lasting 20 seconds.

37-weeks, 1-day gestation by 10-week ultrasound.

Pain rating of 5 on 0 to 10 pain scale with each contraction.

Vaginal exam 4 cm dilated, 50% effaced, -3 station.

Contractions every 3 to 4 minutes, moderate to palpation.

A-blood type, received Rh(D) immune globulin.

Answer and Explanation

Correct Answer : A,C,F

Choice A rationale

Gravida 4 para 3 indicates a history of multiple pregnancies and deliveries, which can increase the risk of uterine atony, postpartum hemorrhage, and placental issues. This client’s obstetric history makes her high-risk due to potential complications associated with multiparity.

Choice B rationale

A fetal heart rate of 136 to 142 beats/minute is within the normal range for a fetus, indicating good fetal well-being. This data point does not place the client at increased risk.

Choice C rationale

Variable decelerations to 120 beats/minute lasting 20 seconds suggest umbilical cord compression, which can lead to fetal hypoxia if persistent and untreated. Variable decelerations are an indicator of potential fetal distress, making this a significant risk factor.

Choice D rationale

A gestation of 37-weeks, 1-day is considered term, and while there may be some risks associated with early-term delivery, this data point alone does not significantly increase risk in a low-risk pregnancy.

Choice E rationale

A pain rating of 5 on a 0 to 10 pain scale with each contraction is indicative of moderate pain, which is expected during labor. Pain severity alone does not increase the client's risk for complications.

Choice F rationale

A vaginal exam showing 4 cm dilation, 50% effacement, and -3 station indicates early labor. However, the -3 station suggests that the fetus is still high in the pelvis, which can be a concern if there is prolonged labor or failure to progress.

Choice G rationale

Contractions every 3 to 4 minutes, moderate to palpation, are consistent with active labor and are not indicative of an increased risk for complications in this context.

Choice H rationale

An A-blood type and receiving Rh(D) immune globulin address Rh incompatibility and prevention of hemolytic disease in the newborn. This data point does not place the client at increased risk.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A rationale

While bulb syringe use is important for clearing the newborn's airways, it is not the immediate priority during the fourth stage of labor. This information can be provided later during routine newborn care education.

Choice B rationale

Newborn screening tests are important for identifying potential health issues, but the fourth stage of labor is focused on stabilizing the mother and infant and initiating breastfeeding. Screening information can be shared during the postpartum period.

Choice C rationale

Techniques to breastfeed are critical information to provide during the fourth stage of labor as it helps establish successful breastfeeding early on. This support can enhance maternal-infant bonding and promote breastfeeding success.

Choice D rationale

Circumcision care is relevant for parents who choose to circumcise their infant, but it is not the immediate priority during the fourth stage of labor. This information can be provided during subsequent postpartum visits.

A. Increased fetal movement. B. Headache and blurred vision. C. Epigastric pain. D. Low back pain with pelvic cramping.

Correct Answer is D

Explanation

Choice D rationale

Low back pain with pelvic cramping can indicate complications such as premature labor or an infection after an amniocentesis.

Choice A rationale

Increased fetal movement is not typically a sign of complications following amniocentesis and may be a normal finding.

Choice B rationale

Headache and blurred vision are concerning symptoms but are not directly related to amniocentesis complications.

Choice C rationale

Epigastric pain can be a sign of other issues, such as preeclampsia, but not specifically related to amniocentesis complications. .

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The nurse reviews the history and physical and nurses' notes to determine risk factors for this client.Which potential issue(s) place the client at risk? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A primigravida client is in the fourth stage of labor after the delivery of a newborn male infant.Which information should the nurse provide?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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The nurse reviews the history and physical and nurses' notes to determine risk factors for this client.
Which potential issue(s) place the client at risk? Select all that apply.