A 39 weeks gestation client presents to the emergency room (ER), contracting every 15 minutes. Each contraction lasts for 30 seconds. The client had spontaneous rupture of membranes (SROM) of clear amniotic fluid for 18 hours. Which of the following nursing interventions is contraindicated?
Intermittent fetal heart auscultation
Nipple stimulation
Administration of IV fluids
Vaginal examinations every hour
The Correct Answer is D
Choice A reason: Intermittent fetal heart auscultation is appropriate when contractions are infrequent and the fetal heart rate is reassuring. It allows monitoring without continuous electronic fetal monitoring, especially in low-risk cases.
Choice B reason: Nipple stimulation is a natural method to promote uterine contractions by stimulating endogenous oxytocin release. However, in this case, contractions are already present, and nipple stimulation is not contraindicated.
Choice C reason: Administration of IV fluids is safe and often necessary to maintain hydration, support uteroplacental perfusion, and prevent maternal hypotension.
Choice D reason: Vaginal examinations every hour are contraindicated because the client has had ruptured membranes for 18 hours. Frequent vaginal exams increase the risk of ascending infection (chorioamnionitis). Vaginal exams should be minimized and performed only when clinically indicated.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A reassuring fetal heart tracing indicates normal fetal oxygenation and wellbeing. This is not a concern and requires no immediate intervention.
Choice B reason: A continuous contraction lasting 2 minutes is abnormal and dangerous. Normal contractions should last 45–90 seconds. Prolonged contractions reduce uteroplacental blood flow, increasing the risk of fetal hypoxia and uterine rupture. This finding requires immediate reporting and intervention.
Choice C reason: Contractions occurring every 4 minutes are within normal labor progression. This is not concerning unless accompanied by abnormal fetal heart patterns or maternal distress.
Choice D reason: A pink mucus plug is a normal sign of cervical change and impending labor. It is expected and not a cause for concern.
Correct Answer is B
Explanation
Choice A reason: The prone position is not recommended in pregnancy. It does not improve uteroplacental blood flow and is impractical for a laboring client.
Choice B reason: The left lateral position is recommended because it relieves pressure from the gravid uterus on the inferior vena cava, improving maternal cardiac output and uteroplacental perfusion. This enhances fetal oxygenation during tachysystole.
Choice C reason: The Trendelenburg position is not appropriate. It increases maternal discomfort, does not improve placental perfusion, and may worsen respiratory compromise.
Choice D reason: The supine position is contraindicated in pregnancy because the uterus compresses the inferior vena cava, reducing venous return and cardiac output. This decreases uteroplacental blood flow and worsens fetal oxygenation.
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