A client is admitted to the labor and delivery unit with contractions noted at 3 minutes apart lasting 45-60 seconds each. She is verbal, alert, and oriented, with clear lungs but an increased respiratory rate, and a regular but elevated cardiac rhythm. The nurse's admission note indicates the client's bed is in a low, locked position, with one side rail up and the call bell in reach, and the fetal heart monitor belt is in place.
What is the most critical immediate action for the nurse to take based on this assessment?
Placing a rolled towel under the client's knees.
Immediately notifying the client's obstetric health care provider.
Administering oxygen to the client via a non-rebreather mask.
Performing a sterile vaginal exam to assess cervical dilation and effacement.
The Correct Answer is D
Choice A rationale
Placing a rolled towel under the client's knees is generally discouraged because it can promote venous stasis in the lower extremities by compressing the popliteal vein, thereby increasing the risk of developing a deep vein thrombosis (DVT). While comfort measures are important, this specific action is not a critical immediate action necessary for safety or to advance care upon admission to the labor unit.
Choice B rationale
The healthcare provider must be notified of the client's admission and status, but this is not the most critical immediate action for the nurse. The immediate priority upon admission is to complete the initial assessment, which includes establishing the fetal heart rate (FHR) baseline (which is currently being monitored) and assessing the stage of labor through a sterile vaginal exam, then notifying the provider with complete findings.
Choice C rationale
Administering supplemental oxygen via a non-rebreather mask (NRB) is indicated for signs of maternal hypoxemia (low oxygen saturation) or for fetal distress. Although the client has an increased respiratory and cardiac rate, her lungs are clear, and she is alert, suggesting anxiety or labor pain is the likely cause. Oxygen is not immediately required without evidence of true hypoxemia.
Choice D rationale
Performing a sterile vaginal exam (SVE) to assess cervical dilation and effacement is a critical, immediate action upon admission to the labor unit to determine the stage of labor. This information is essential for triage, ongoing management, and planning. It provides the baseline data needed to compare against subsequent exams and to communicate the client's status effectively to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Contractions that are only 20 mm Hg in strength with a baseline resting tone of 5 to 8 mm Hg indicate hypotonic uterine dysfunction. This is characterized by insufficient uterine contraction power, not hypertonic resting tone. Oxytocin is an exogenous hormone that mimics the effects of the naturally released hormone, acting on uterine smooth muscle cells to increase the frequency, duration, and strength (intensity) of the contractions, which should ideally be 50 to 80 mm Hg during active labor.
Choice B rationale
Suggesting relaxation is inappropriate because these contraction patterns are ineffective and unlikely to spontaneously strengthen enough to cause adequate cervical change. Hypotonic contractions typically lead to a protracted labor pattern. The smooth muscle fibers of the uterus require sufficient stimulation to fully activate the contractile proteins actin and myosin. The low intensity and inadequate pressure of these contractions will not result in optimal cervical effacement and dilation.
Choice C rationale
These contractions are hypotonic, not hypertonic. Hypertonic contractions are characterized by high resting tone (above 15 mm Hg) and often painful, ineffective, erratic contractions. A period of rest is generally recommended for hypertonic contractions to reduce uterine irritability and oxygen consumption. However, for hypotonic dysfunction, augmentation (Choice A) is usually required to safely expedite the labor process and reduce risk of infection.
Choice D rationale
While upright positions like sitting or walking can use gravity to help the fetal head apply pressure to the cervix and stimulate endogenous oxytocin release, this response is less effective than recognizing the need for potential pharmacological augmentation. The contractions are described as rarely higher than 20 mm Hg, suggesting a significant need for intervention beyond simple position change to achieve the necessary 50 to 80 mm Hg intensity for progression.
Correct Answer is B
Explanation
Choice A rationale
The presence of varicose veins (dilated, tortuous superficial veins) is a common finding during pregnancy due to increased venous pressure and is a risk factor for deep vein thrombosis (DVT). While it warrants monitoring for local signs of inflammation or pain, it is a chronic condition and not an acute sign of a severe complication like a pulmonary embolism (PE).
Choice B rationale
Dyspnea (difficulty breathing) is an acute and concerning symptom, especially in a client with a recent deep vein thrombosis (DVT), as it is a cardinal sign of a pulmonary embolism (PE). A PE occurs when a clot, often originating in the leg, embolizes and obstructs the pulmonary vasculature. This is a life-threatening complication that requires immediate intervention.
Choice C rationale
A pulse of 92 beats/min is slightly elevated but often an expected physiologic response in the postpartum period due to cardiovascular readjustment or mild pain/stress. While tachycardia can be a sign of a pulmonary embolism, a rate of 92 is not severe enough on its own to be the most concerning finding compared to acute respiratory distress (dyspnea). The normal adult pulse rate is 60 to 100 beats/min.
Choice D rationale
A blood pressure of 136/88 mm Hg is considered elevated (prehypertensive or stage 1 hypertension) but is not immediately life-threatening. While it requires follow-up, it is less acutely concerning than dyspnea, which suggests a severe respiratory or circulatory compromise like a pulmonary embolism. The client is not currently in a hypertensive crisis (e.g., ≥ 180/120 mm Hg).
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