A client at 37-weeks, 1-day gestation by a 10-week ultrasound, presents to labor and delivery with contractions every 3 to 4 minutes for the last 2 hours.The vaginal exam shows the client is 4 cm dilated, 50% effaced, -3 station.
The membranes are intact.
Contractions occur every 3 to 4 minutes per monitor, lasting 60 seconds, moderate by palpation.
Fetal heart rate is 136 beats/minute with accelerations noted; no decelerations are noted.
The estimated fetal weight by Leopold's is 6 pounds (2.72 kg). The prenatal course is unremarkable, with normal labs.
The client's blood type is A-. An Rh(D) immune globulin injection was received at 28-weeks.

37-weeks, 1-day.

Pain rating of 5.

Vaginal exam.

Contractions every 3-4 minutes.

A- blood type.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Being 37-weeks, 1-day gestation is considered term. This timing indicates the fetus is likely mature and ready for birth, which reduces the risk of complications compared to preterm delivery. However, early-term delivery can still have some associated risks, such as respiratory issues or feeding difficulties.

Choice B rationale

A pain rating of 5 during contractions is within the expected range during active labor. Pain management is an important aspect of labor care, but it does not inherently increase or decrease the risk of complications.

Choice C rationale

The vaginal exam findings of 4 cm dilation, 50% effacement, and -3 station indicate early labor progression. However, the negative station suggests the fetus is still high in the pelvis, which could pose a risk if labor stalls or if there is cephalopelvic disproportion.

Choice D rationale

Contractions every 3 to 4 minutes are consistent with active labor. Regular and moderate contractions are expected and necessary for labor to progress. This data point alone does not increase the risk for complications.

Choice E rationale

An A- blood type with Rh(D) immune globulin received at 28 weeks is managed appropriately to prevent Rh sensitization. Rh(D) immune globulin reduces the risk of hemolytic disease of the fetus and newborn in subsequent pregnancies, making it an important preventative measure but not a current risk factor. .

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Correct Answer is B

Explanation

Choice A rationale

Administering oxygen would not be the priority as the fetal heart rate is normal and there are no abnormal fetal movements or signs of distress. Oxygen administration is typically reserved for cases where there is evidence of fetal hypoxia or distress.

Choice B rationale

Checking cervical dilation is essential as it provides critical information about the progress of labor and helps in determining the next steps in management. It ensures that the labor is progressing appropriately and identifies if there is a need for any medical interventions.

Choice C rationale

Starting an intravenous fluid bolus would not be the first action in this scenario as the client does not show signs of dehydration or hypotension. Fluid bolus is generally reserved for cases where there is evidence of hypovolemia or to support hemodynamic stability.

Choice D rationale

Preparing for immediate delivery is not necessary at this stage as there are no signs of fetal distress or urgent complications. The client is only 37 weeks gestation and regular assessment is crucial to ensure timely and appropriate interventions without premature actions.

A. Obtain a heel stick blood glucose level. B. Swaddle the infant in a warm blanket. C. Place a pulse oximeter on the heel. D. Document the findings in the record.

Correct Answer is A

Explanation

Choice A rationale

The symptoms of jitteriness, hypotonia, weak cry, and low temperature can indicate hypoglycemia in a newborn. Obtaining a heel stick blood glucose level is crucial to confirm the diagnosis and provide appropriate treatment.

Choice B rationale

While keeping the infant warm is important, it does not address the underlying issue of potential hypoglycemia, which needs to be identified and treated promptly.

Choice C rationale

Placing a pulse oximeter on the heel assesses oxygen saturation, which is not directly related to the symptoms described. The primary concern here is glucose level, not oxygen saturation.

Choice D rationale

Documenting the findings is important but does not provide immediate intervention for potential hypoglycemia, which requires urgent glucose level assessment and treatment if necessary. .

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Naxlex Comprehensive Predictor Exams

A client at 37 weeks gestation presents with contractions every 3 to 4 minutes, lasting 60 seconds.The fetal heart rate is noted to be 140 bpm, and no abnormal fetal movements are observed.The client reports no pain and normal laboratory results.Which action should the nurse implement first?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

A primigravida client is in the fourth stage of labor after the delivery of a newborn male infant.Which information should the nurse provide?

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