A 33-year-old woman is in active labor. What should the nurse's next action be if the client's white blood cell (WBC) count is 25,000/mm3?
Normal WBC Range: 5,000-10,000/mm3
Immediately inform the health care provider
Repeat CBC STAT
Immediately begin antibiotic therapy
Recognize that this count is an acceptable range for labor and continue to monitor
The Correct Answer is D
A. Informing the healthcare provider immediately is not necessary in this case because the elevated WBC count is expected during active labor. Although WBC counts are normally 5,000–10,000/mm³, physiological leukocytosis occurs in pregnancy and especially in labor, often reaching 20,000–30,000/mm³ due to stress and the inflammatory response.
B. Repeating a CBC STAT is not required unless there are other signs of infection or clinical deterioration. A WBC of 25,000/mm³ alone, in the absence of fever, foul-smelling discharge, or other symptoms, is typically a normal labor-related change.
C. Beginning antibiotic therapy immediately is unnecessary without evidence of infection such as fever, uterine tenderness, or positive cultures. Administering antibiotics based solely on leukocytosis could lead to unnecessary medication exposure.
D. Recognizing that this count is an acceptable range for labor and continuing to monitor is correct. Physiologic leukocytosis during active labor can elevate WBC counts to 25,000–30,000/mm³. The nurse should continue routine assessment and monitor for any signs of infection, but no immediate intervention is needed solely for this laboratory value.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While preterm infants are at increased risk for hypoglycemia due to limited glycogen stores and immature metabolic regulation, dexamethasone does not directly prevent hypoglycemia. Its pharmacologic action is not related to neonatal blood sugar management.
B. Dexamethasone is a corticosteroid given to pregnant clients at risk of preterm birth, typically between 24 and 34 weeks gestation. The medication crosses the placenta and stimulates fetal lung epithelial cells to produce surfactant, a substance that reduces alveolar surface tension, enabling the lungs to remain open for effective gas exchange after birth. By accelerating lung development, dexamethasone significantly reduces the risk of respiratory distress syndrome (RDS), intraventricular hemorrhage, necrotizing enterocolitis, and neonatal mortality. The most benefit is observed when delivery occurs 24–48 hours after the first dose but within 7 days of administration.
C. While corticosteroid therapy can have secondary benefits, including a reduction in intraventricular hemorrhage, this is not the primary purpose of dexamethasone administration. The main goal remains enhancing fetal lung maturity.
D. Dexamethasone is not a tocolytic and does not suppress preterm labor contractions. Tocolytic medications, such as magnesium sulfate, nifedipine, or indomethacin, are used for short-term suppression of uterine activity to allow time for corticosteroids to enhance fetal lung maturity.
Correct Answer is C
Explanation
A. Placing the client on her left lateral side is an appropriate intervention for variable or late decelerations, which may indicate uteroplacental insufficiency or cord compression, but it is not required for early decelerations, as these are generally benign and related to fetal head compression.
B. Checking maternal vital signs is part of routine monitoring, but it is not the priority intervention specifically related to early decelerations. Maternal vital signs are unlikely to immediately change the interpretation or management of early decelerations.
C. Documenting the findings is appropriate because early decelerations are a normal, expected pattern during labor. They are characterized by gradual decreases in fetal heart rate that mirror uterine contractions, typically reaching the nadir at the peak of the contraction. This pattern reflects fetal head compression as the fetus descends through the birth canal and does not indicate fetal compromise. No immediate interventions are required other than continued monitoring.
D. Applying oxygen is generally reserved for situations where there is fetal distress, such as with late or variable decelerations accompanied by abnormal baseline or variability. Early decelerations are not caused by fetal hypoxia, so oxygen administration is unnecessary.
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