Share This Link

Fetal baseline rate increasing at least 5 beats per minute:An increase in the fetal baseline heart rate of 5 beats per minute is typically not associated with uteroplacental insufficiency. A baseline increase could indicate early signs of fetal stimulation, such as from fetal movement or excitement, but it does not align with the characteristic response to uteroplacental insufficiency, which usually causes signs of distress like late decelerations or fetal heart rate variability.

A shallow deceleration occurring with the beginning of contractions:A shallow deceleration with the onset of contractions may suggest early decelerations, which are typically caused by fetal head compression during labor. Early decelerations are not typically associated with uteroplacental insufficiency, which generally leads to later decelerations. Early decelerations are generally considered benign and do not indicate oxygen deprivation or fetal distress.

Variable decelerations, too unpredictable to count:Variable decelerations, characterized by abrupt drops in fetal heart rate with varying timing and duration, are usually caused by umbilical cord compression. While these decelerations can indicate fetal distress, they are not directly linked to uteroplacental insufficiency. Uteroplacental insufficiency typically leads to late decelerations, not variable decelerations.

Decrease the heart rate of the fetus:Lying on the left side can sometimes help improve fetal oxygenation, especially if there is a concern about reduced blood flow from compression of the inferior vena cava, which can occur when the mother lies on her back. However, the primary rationale for this position is to prevent supine hypotension, not specifically to decrease fetal heart rate. In fact, side-lying can promote better oxygen exchange, which can indirectly benefit the fetal heart rate.

Aid the women while she pushes:While a left-side lying position may offer comfort during labor and can help with uterine positioning, it is not specifically intended to aid in the pushing phase. Positions such as squatting or hands-and-knees are generally more helpful during the pushing phase because they can facilitate effective pushing and help the baby descend into the birth canal. The left-side position is more about circulation and preventing hypotension.

Prevent the client from falling out of bed:While lying on the left side may make the woman feel more stable, the primary reason for this position is to prevent supine hypotension, not to prevent her from falling out of bed. The nurse would ensure safety by using appropriate bed rails and monitoring, but the primary concern is supporting optimal circulation, not preventing falls.

At the umbilicus:After delivery, the fundus is typically located at or just below the umbilicus in the immediate postpartum period, but it will gradually descend over the next few days. By 8 hours postpartum, the fundus is often slightly below the umbilicus, not directly at the umbilicus. The fundus will continue to shrink in size and move downward toward the pelvic region as the uterus contracts and involutes.

At a non-palpable depth:A fundus that is non-palpable is generally expected later in the postpartum period, typically by 10-14 days after delivery, as the uterus contracts and returns to its pre-pregnancy size. At 8 hours postpartum, the fundus is still palpable, generally just below the umbilicus, and should be evaluated for firmness and position.

Just above the symphysis pubis:
The fundus is usually higher than the symphysis pubis at 8 hours postpartum, as it is still in the process of descending from the higher position it occupied during pregnancy. It would be expected to be just below the umbilicus or about 1 to 2 finger widths below it. By the second or third day postpartum, the fundus begins to move lower toward the symphysis pubis as it continues to involute.

Sublimation:Sublimation refers to a defense mechanism where a person redirects potentially negative emotions or impulses into socially acceptable behaviors or activities. While this is a psychological concept, it does not apply to the father’s behavior immediately after birth. The father's actions, such as gazing at his baby and bonding, are not a result of sublimation but rather a normal part of bonding and attachment.

Claiming:Claiming refers to the process where parents identify specific traits or characteristics in their newborn that they feel emotionally connected to, such as "He has my eyes" or "She has your nose." While the father might be engaging in claiming behaviors as he bonds with his baby, this term is more focused on recognizing physical attributes, rather than the intense emotional connection and captivation that is reflected in the scenario.

Mutuality:
Mutuality involves the reciprocal relationship between the newborn and the parents, where both give and receive emotional responses. It develops as the baby and parent interact, such as through eye contact, touch, and vocalizations. However, mutuality is a broader, ongoing process, while the father's behavior in this instance reflects a more specific emotional attachment and admiration, which aligns more closely with engrossment.

Urinate every two to three hours:While frequent urination is important for general bladder health, particularly in the immediate postpartum period to avoid urinary retention, it is not directly related to preventing complications associated with elevated fibrinogen levels. Fibrinogen's main risk is related to clotting, and frequent urination does not affect this process.

Eat a diet high in protein:While eating a balanced diet with adequate protein is essential for postpartum recovery and tissue healing, it does not directly address the increased fibrinogen levels or the potential for clotting. A high-protein diet does not significantly reduce the risks related to hypercoagulability during the postpartum period, which is primarily managed through careful monitoring and preventive measures such as using stool softeners or encouraging movement.

Walk:While walking is beneficial for overall health and can help improve circulation, reducing the risk of DVT and promoting postpartum recovery, walking alone may not be sufficient to counteract the increased clotting risk from elevated fibrinogen levels. While movement is important to prevent clots, the use of stool softeners to prevent constipation is a more direct and targeted intervention for preventing strain, which could trigger clot formation. Therefore, walking, while helpful, is not the most specific measure to prevent complications related to increased fibrinogen.

Beginning epidural anesthesia:Epidural anesthesia is typically not initiated in the early phase of labor unless there is a specific indication or a desire for significant pain relief early in the process. An epidural is more commonly offered in the later stages of labor, when the pain is more intense and the cervix is further dilated. Starting an epidural too early could expose the mother to unnecessary risks and is generally not recommended unless it's requested or deemed medically necessary.

Using an opioid antagonist, such as Butorphanol:Opioids, including Butorphanol, can have side effects such as drowsiness, nausea, and respiratory depression in both the mother and fetus. These medications are more commonly used in later stages of labor or when more potent pain relief is required. Additionally, opioid antagonists like Butorphanol may not be the best choice for a client who is experiencing anxiety and mild to moderate pain in the early phase, as they may not provide the relaxation and coping support that non-pharmacological methods like effleurage offer.

Immersing the client in hot water in a pool or Jacuzzi:While immersion in water can be a helpful method of pain relief, especially during labor, it is generally recommended in the later stages of labor or when the cervix is dilated enough for water immersion to be safely utilized. Immersion in hot water may not be appropriate for all patients and could potentially lead to risks like overheating or changes in blood pressure. Additionally, the early phase of labor often involves less intense pain, and less invasive methods like effleurage are usually preferred first to manage discomfort and reduce anxiety.

A postpartum individual can have lochia rubra at 5 weeks postpartum:Lochia rubra is the first stage of lochia, consisting of bright red blood and tissue, and is typically seen in the first 3-4 days postpartum. By 5 weeks postpartum, the lochia should no longer be in the rubra phase, and the discharge should have progressed to lochia serosa or alba. If the client is still experiencing lochia rubra at 5 weeks, this could indicate a problem, such as retained placental tissue or infection, and requires further evaluation.

A postpartum individual should not have any lochia at 5 weeks postpartum:While it is true that lochia should be minimal or absent by 5 weeks postpartum, it is not uncommon for some women to still experience small amounts of lochia, particularly in the form of lochia alba, which can last up to 6 weeks. The type of discharge should be assessed, and if the discharge is abnormal (such as foul-smelling or accompanied by other symptoms), the nurse should investigate further. However, some amount of discharge, especially lochia alba, can be normal at this stage.

A postpartum individual can have lochia serosa up to 6 weeks postpartum:Lochia serosa, which is pinkish or brownish in color and consists of blood, mucus, and uterine tissue, usually occurs between 4 to 10 days postpartum. It is not typically seen at 5 weeks postpartum unless there is a delay in the normal progression of lochia stages. By 5 weeks postpartum, lochia serosa should have already transitioned to lochia alba, a whitish or yellowish discharge.

Fetal heart monitoring:Nurses are trained to monitor fetal heart rates, interpret patterns, and identify signs of distress, but this task is typically within the scope of a registered nurse's (RN) practice. It may not involve the critical decision-making or advanced skills associated with the highest level of licensure.

Taking specimens to the lab:Taking specimens to the laboratory is a necessary but routine part of care. While it is important for ensuring proper diagnostic testing, it is a lower-level task and does not demonstrate the highest level of nursing practice. This task is often delegated or performed as part of standard nursing duties.

Giving a client a bed bath:While important for patient care and comfort, giving a client a bed bath is a basic nursing task that does not demonstrate working at the highest level of licensure. It is a fundamental nursing activity often carried out by nurses, nursing assistants, or other support staff. The act of providing a bed bath is part of the foundational skill set and does not require advanced knowledge or decision-making that would demonstrate the highest level of practice.