Nokea
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
- A. Prepare for a cesarean birth.
- B. Assist the client to an upright position.
- C. Prepare for an immediate vaginal delivery.
- D. Assist the client to turn onto her side.
Correct Answer: D
Rationale: Correct Answer: D - Assist the client to turn onto her side.
Rationale:
1. Side-lying position improves placental perfusion and circulation, optimizing blood pressure.
2. This position also helps in relieving pressure on major blood vessels, preventing hypotension.
3. It is a non-invasive intervention that can be quickly implemented in the labor setting.
Summary of Other Choices:
A: Preparing for a cesarean birth is not indicated based solely on the client's blood pressure reading.
B: Assisting the client to an upright position may further decrease blood pressure and compromise perfusion.
C: Immediate vaginal delivery is not warranted solely based on the client's blood pressure and cervical dilation.
You may also like to solve these questions
A patient has just acknowledged that she is 20 weeks pregnant and confides to the nurse that she has a daily heroin habit. The nurse discusses treatment options for the patient. Which patient statement requires follow-up?
- A. "My plan is to visit the outpatient clinic daily for treatment."
- B. "will see my health care provider at least every 2 weeks."
- C. "My baby will not have to go through withdrawal when I take methadone."
- D. "With oral methadone, my baby and I are at decreased risk of infection."
Correct Answer: B
Rationale: The correct answer is B because seeing the healthcare provider every 2 weeks may not be frequent enough for monitoring a pregnant patient with a heroin habit. Regular monitoring is crucial for the well-being of both the mother and the baby. Option A shows a proactive approach for daily treatment, Option C is incorrect as methadone does not eliminate the risk of withdrawal in newborns, and Option D is incorrect as methadone does not reduce the risk of infection. Regular and close monitoring is essential in such cases to ensure the safety and health of both the mother and the baby.
A nurse is assessing a newborn who was born Post term. Which of the following findings should the nurse expect?
- A. A Rh-negative mother who has an Rh- positive infant
- B. A Rh "“positive mother who has an Rh- negative infant
- C. A Rh-positive mother who has an Rh- positive infant
- D. A Rh- negative mother who has an Rh- negative infant
Correct Answer: A
Rationale: The correct answer is A: A Rh-negative mother who has an Rh-positive infant. Post-term infants are at higher risk for conditions such as Rh incompatibility. Since the mother is Rh-negative and the infant is Rh-positive, there is a potential for Rh incompatibility, leading to hemolytic disease of the newborn. This occurs when the mother's antibodies attack the infant's red blood cells.
Choice B is incorrect because Rh incompatibility occurs when the mother is Rh-negative and the infant is Rh-positive. Choice C is incorrect as both mother and infant being Rh-positive do not lead to Rh incompatibility. Choice D is incorrect because Rh incompatibility does not occur when both mother and infant are Rh-negative.
A client at 35 weeks' gestation reports sharp abdominal pain and vaginal bleeding. What condition should the nurse suspect?
- A. Placenta previa.
- B. Abruptio placentae.
- C. Preterm labor.
- D. Chorioamnionitis.
Correct Answer: B
Rationale: The correct answer is B: Abruptio placentae. This condition presents with sharp abdominal pain and vaginal bleeding, typically occurring in the third trimester. It is caused by the premature separation of the placenta from the uterine wall. The pain is often severe due to the bleeding and can lead to fetal distress. Placenta previa (A) presents with painless vaginal bleeding, preterm labor (C) typically involves regular contractions and cervical changes, and chorioamnionitis (D) is characterized by fever and uterine tenderness.
A nurse is caring for a client who is in active labor and notes late decelerations in the FRH on the external fetal.... Which of the following actions should the nurse take first?
- A. Change the client's position.
- B. Palpate the uterus to assess for tachysystole.
- C. Increase the client's IV infusion rate.
- D. Administer oxygen at 10 L/min via nonrebreather mask.
Correct Answer: A
Rationale: The correct answer is A: Change the client's position. Late decelerations indicate uteroplacental insufficiency, which can be caused by pressure on the vena cava from the uterus. Changing the client's position can alleviate this pressure, improving fetal oxygenation. Palpating the uterus or increasing IV infusion rate may not address the underlying issue. Administering oxygen is important but should come after addressing the positional issue to ensure optimal oxygen delivery to the fetus.
The nurse is assessing a client with suspected placenta previa. Which finding supports this diagnosis?
- A. Painful, bright red bleeding.
- B. Painless, bright red bleeding.
- C. Hard, rigid abdomen.
- D. Decreased fetal movements.
Correct Answer: B
Rationale: The correct answer is B: Painless, bright red bleeding. Placenta previa is characterized by painless vaginal bleeding due to the placenta covering the cervical os. Bright red blood indicates fresh bleeding from the lower uterus. This finding supports the diagnosis as it aligns with the classic presentation of placenta previa.
A: Painful, bright red bleeding is not characteristic of placenta previa, as the bleeding is usually painless.
C: A hard, rigid abdomen is more indicative of a uterine rupture or abruption, not placenta previa.
D: Decreased fetal movements are not directly associated with placenta previa; this finding may suggest fetal distress but is not specific to this condition.