While assisting with a vacuum extraction birth, what should the nurse immediately report to the physician?
Maternal pulse rate of 100 bpm.
Maternal blood pressure of 120/70 mm Hg.
Decrease in intensity of uterine contractions.
Persistent fetal bradycardia below 100 bpm.
The Correct Answer is D
The correct answer is: d. Persistent fetal bradycardia below 100 bpm.
Choice A: Maternal pulse rate of 100 bpm
A maternal pulse rate of 100 beats per minute (bpm) is slightly elevated but not uncommon during labor due to the physical exertion and stress involved. The normal range for an adult’s resting heart rate is typically between 60 and 100 bpm. While it is important to monitor the maternal pulse, it is not an immediate cause for concern unless accompanied by other symptoms such as hypotension, chest pain, or signs of distress.
Choice B: Maternal blood pressure of 120/70 mm Hg
A maternal blood pressure of 120/70 mm Hg is within the normal range. Normal blood pressure for adults is generally considered to be around 120/80 mm Hg. This reading indicates that the mother is maintaining stable blood pressure during labor, which is a positive sign. Therefore, this does not require immediate reporting to the physician.
Choice C: Decrease in intensity of uterine contractions
A decrease in the intensity of uterine contractions can be concerning as it may indicate ineffective labor, which could prolong the delivery process. However, this is typically managed by adjusting oxytocin levels or other interventions and does not require immediate reporting unless it leads to other complications such as fetal distress.
Choice D: Persistent fetal bradycardia below 100 bpm
Persistent fetal bradycardia below 100 bpm is a significant concern and should be immediately reported to the physician. Normal fetal heart rate ranges from 110 to 160 bpm. Bradycardia, defined as a heart rate below 110 bpm, can indicate fetal distress, hypoxia, or other complications that may require urgent intervention to ensure the safety of the fetus. Persistent bradycardia, especially below 100 bpm, necessitates immediate medical attention to assess and address the underlying cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The nurse's priority in this situation is the client's blood pressure of 80/56 mm Hg. Opioid epidural analgesia can cause a drop in blood pressure, known as hypotension. Hypotension can be a significant concern during labor, as it may reduce blood flow to the placenta and compromise the baby's well-being. Therefore, it is crucial for the nurse to address this finding promptly to prevent any adverse effects on both the mother and the baby. The nurse may need to administer intravenous fluids, adjust the dosage of the opioid medication, or take other appropriate actions to raise the blood pressure to a safer level.
Choice B reason:
While profuse itching (choice B) can be a common side effect of opioids, it is not the nurse's priority in this situation. Itching, also known as pruritus, can be managed with antihistamines or other supportive measures, but it is not an immediate threat to the client's well-being.
Choice C reason:
The client reporting weakness of the lower extremities (choice C) is an expected side effect of epidural analgesia. Epidurals can cause temporary paralysis or weakness in the lower body due to the local anesthetic's effects on the nerves. While it's essential to monitor and support the client during this time, it is not the priority over the potentially dangerous drop in blood pressure.
Choice D reason:
A temperature of 38.2°C (100.8 F) (choice D) may indicate a fever, but it is not the nurse's priority in this specific situation of opioid epidural analgesia during labor. Fever during labor could have various causes, and the nurse should investigate and manage it appropriately. However, addressing the client's blood pressure takes precedence, as hypotension can have immediate and significant consequences.
Correct Answer is A
Explanation
Assist the client to turn onto her side. This is the correct answer because turning the client onto her side can improve blood flow to the placenta and increase fetal oxygenation. Hypotension is a common cause of decreased uteroplacental perfusion, which can lead to fetal distress and late decelerations on the fetal monitor. The nurse should also administer oxygen, increase IV fluids, and notify the provider. • Choice B reason:
Prepare for an immediate vaginal delivery. This is not the correct answer because there is no indication that the client is ready for delivery. The client has 6 cm of cervical dilation, which means she is still in the active phase of labor. The second stage of labor begins when the cervix is fully dilated (10 cm) and ends with delivery of the baby. Preparing for an immediate vaginal delivery would not address the cause of hypotension or improve fetal oxygenation. • Choice C reason:
Prepare for a cesarean birth. This is not the correct answer because there is no indication that the client needs a cesarean birth. A cesarean birth may be indicated if there are signs of fetal compromise, such as severe variable or late decelerations, or maternal complications, such as placenta previa or cord prolapse. However, these conditions are not present in this scenario. Preparing for a cesarean birth would not address the cause of hypotension or improve fetal oxygenation. • Choice D reason:
Assist the client to an upright position. This is not the correct answer because placing the client in an upright position can worsen hypotension and decrease uteroplacental perfusion. An upright position can increase pressure on the inferior vena cava and reduce venous return to the heart. This can lower cardiac output.
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