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The nurse is assessing a client in labor with variable decelerations on the fetal monitor. What is the priority intervention?
- A. Increase oxytocin infusion.
- B. Reposition the client.
- C. Administer oxygen at 10 L/min.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: Repositioning the client can alleviate umbilical cord compression, the most common cause of variable decelerations.
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A client comes to the labor and delivery with polyhydramnios. She was admitted and her membrane ruptures is clear and odorless, but the fetal heart monitor indicate bradycardia and variable decelerations. What should action should be taken next?
- A. Perform vaginal exam (lot of fluid, check to see where baby is)
- B. High fowler position
- C. Warm saline soak vaginal
- D. Perform Leopold maneuver
Correct Answer: A
Rationale: In this scenario, with the presence of polyhydramnios and clear, odorless amniotic fluid, the fetal heart monitor indicating bradycardia and variable decelerations indicates a potential umbilical cord compression due to excessive amniotic fluid volume. It is crucial to perform a vaginal exam promptly as this can help assess the position of the baby and determine if there is a cord prolapse or any other complications that may be affecting the fetal heart rate. The baby's position needs to be identified quickly to address potential issues and ensure a safe delivery process.
The nurse is caring for a client with preeclampsia. What is the most important assessment?
- A. Daily weight.
- B. Urine protein levels.
- C. Fetal heart rate.
- D. Blood pressure.
Correct Answer: D
Rationale: Blood pressure monitoring is critical to prevent complications such as eclampsia and placental issues in preeclampsia.
The nurse is caring for a client with gestational hypertension. What symptom should be reported immediately?
- A. Headache unrelieved by acetaminophen.
- B. Slight swelling of the hands.
- C. Mild nausea after eating.
- D. Fatigue at the end of the day.
Correct Answer: A
Rationale: Headache unrelieved by medication may indicate worsening gestational hypertension or preeclampsia.
Early PPH is defined as blood loss greater than ____ 24h after delivery
- A. 500 mL 24h after normal delivery
- B. 1000 48h after c/s (lat
- C. 1500 mL after 48hr
- D. 750 mL after 24h vaginal delivery
Correct Answer: D
Rationale: Early postpartum hemorrhage (PPH) is defined as blood loss greater than 500 mL within the first 24 hours after vaginal delivery. This definition is crucial because it helps healthcare providers identify and promptly address any excessive bleeding that may occur in the immediate postpartum period. Monitoring postpartum bleeding is essential to prevent complications related to PPH, such as maternal anemia, hypovolemic shock, and even maternal death. By knowing the definition of early PPH, healthcare providers can take timely interventions to manage and treat postpartum hemorrhage effectively.
The nurse knows that contraindication of the induction of labor includes:
- A. Placenta previa
- B. Diabetes mellitus
- C. PROM
- D. Isoimmunization
Correct Answer: A
Rationale: Placenta previa is a contraindication for the induction of labor because the placenta partially or completely covers the cervix. Inducing labor in this situation can lead to complications such as excessive bleeding and compromised blood flow to the baby. Therefore, it is important to avoid inducing labor in cases of placenta previa to ensure the safety of both the mother and the baby.