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?

Administer oxygen.

Check cervical dilation.

Start an intravenous fluid bolus.

Prepare for immediate delivery.

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is C

Explanation

Choice A rationale

Drinking water is not necessary before a triple screen analysis. This test does not require a full bladder.

Choice B rationale

The left lateral tilt position is typically used to prevent supine hypotensive syndrome in pregnant women during ultrasounds, not for a blood draw.

Choice C rationale

A triple screen analysis involves drawing blood from the mother to test for specific markers that indicate the risk of certain fetal abnormalities. Blood sampling is necessary for the analysis.

Choice D rationale

Applying an external fetal monitor is unrelated to a triple screen analysis, which focuses on maternal blood markers rather than fetal heart rate monitoring.

A. Gravida 4: para 3. B. Fetal heart rate 136 to 142 beats/minute. C. Variable decelerations to 120 beats/minute lasting 20 seconds. D. 37-weeks, 1-day gestation by 10-week ultrasound. E. Pain rating of 5 on 0 to 10 pain scale with each contraction. F. Vaginal exam 4 cm dilated, 50% effaced, -3 station. G. Contractions every 3 to 4 minutes, moderate to palpation. H. A-blood type, received Rh(D) immune globulin.

Correct Answer is ["A","C","F"]

Explanation

Choice A rationale

Gravida 4 para 3 indicates a history of multiple pregnancies and deliveries, which can increase the risk of uterine atony, postpartum hemorrhage, and placental issues. This client’s obstetric history makes her high-risk due to potential complications associated with multiparity.

Choice B rationale

A fetal heart rate of 136 to 142 beats/minute is within the normal range for a fetus, indicating good fetal well-being. This data point does not place the client at increased risk.

Choice C rationale

Variable decelerations to 120 beats/minute lasting 20 seconds suggest umbilical cord compression, which can lead to fetal hypoxia if persistent and untreated. Variable decelerations are an indicator of potential fetal distress, making this a significant risk factor.

Choice D rationale

A gestation of 37-weeks, 1-day is considered term, and while there may be some risks associated with early-term delivery, this data point alone does not significantly increase risk in a low-risk pregnancy.

Choice E rationale

A pain rating of 5 on a 0 to 10 pain scale with each contraction is indicative of moderate pain, which is expected during labor. Pain severity alone does not increase the client's risk for complications.

Choice F rationale

A vaginal exam showing 4 cm dilation, 50% effacement, and -3 station indicates early labor. However, the -3 station suggests that the fetus is still high in the pelvis, which can be a concern if there is prolonged labor or failure to progress.

Choice G rationale

Contractions every 3 to 4 minutes, moderate to palpation, are consistent with active labor and are not indicative of an increased risk for complications in this context.

Choice H rationale

An A-blood type and receiving Rh(D) immune globulin address Rh incompatibility and prevention of hemolytic disease in the newborn. This data point does not place the client at increased risk.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In preparing a gravid client for a triple screen analysis, which action should the nurse take?

Correct Answer is C

Explanation

The nurse reviews the history and physical and nurses' notes to determine risk factors for this client.Which potential issue(s) place the client at risk? Select all that apply.

Correct Answer is ["A","C","F"]

Explanation

During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment.Which technique should the nurse implement to evaluate the leakage?

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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?