A client is in labor and actively pushing.
The nurse observes decelerations in the fetal heart rate and the fetal head is at the vaginal station.
What condition is the client most likely experiencing, what are 2 actions the nurse should take to address that
condition, and what are 2 parameters the nurse should monitor to assess the client’s progress?
The client is in the second stage of labor.
The nurse should apply an oxygen mask to the client.
The nurse should press down on the uterine fundus.
The nurse should monitor the client’s vital signs and fetal heart rate.
Correct Answer : A,B,D
Choice A rationale:
The client is in the second stage of labor because she is actively pushing and the fetal head is at the vaginal station.
The second stage of labor is defined as the time from full cervical dilation to the birth of the baby. It is characterized by strong,
regular contractions and the urge to push.
Decelerations in the fetal heart rate can occur during the second stage of labor due to a variety of factors, including head
compression, cord compression, and uteroplacental insufficiency.
Choice B rationale:
The nurse should apply an oxygen mask to the client to increase the oxygen supply to the fetus.
This can help to improve fetal heart rate and prevent further decelerations.
Oxygen is a vital nutrient for the fetus, and it is essential for maintaining a normal fetal heart rate.
When the fetal heart rate decelerates, it is a sign that the fetus is not getting enough oxygen.
Applying an oxygen mask to the mother can help to increase the amount of oxygen that is available to the fetus.
Choice D rationale:
The nurse should monitor the client's vital signs and fetal heart rate to assess the client's progress and the well-being of the
fetus.
Vital signs, such as blood pressure, pulse, and respiration rate, can provide important information about the mother's health
and how she is coping with labor.
The fetal heart rate is a direct measure of the fetus's well-being.
By monitoring these parameters, the nurse can identify any potential problems and intervene as needed.
Additional notes:
The nurse should also encourage the client to change positions, as this can help to relieve cord compression.
The nurse should also prepare for the possibility of a rapid delivery, as decelerations in the fetal heart rate can sometimes be a
sign of fetal distress.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Evaluating the side effects of analgesia is not the priority action in this situation. While it's important to assess for potential
side effects, the client's immediate need to use the bathroom takes precedence.
Analgesia might contribute to urinary retention in some cases, but it's not the most likely reason for the client's request.
Promptly addressing the client's need to void helps prevent bladder distention, discomfort, and potential urinary tract
infections.
Choice B rationale:
Using a wheelchair is not necessary in most cases after a vaginal birth.
Early ambulation is generally encouraged to promote circulation, prevent blood clots, and aid in recovery.
Requiring a wheelchair could delay the client's ability to void and might make her feel less independent.
Choice C rationale:
Advising the client to remain in bed is not recommended practice after a vaginal birth.
Prolonged bed rest can increase the risk of complications, such as blood clots, muscle weakness, and delayed bowel function.
Early ambulation, as tolerated, is crucial for promoting physical recovery and preventing postpartum complications.
Correct Answer is B
Explanation
Rationale for Choice A:
Checking the client's fundus is an important assessment in the postpartum period, but it is not the most immediate action
when a large amount of lochia rubra with clots is present. A boggy or displaced fundus could indicate subinvolution or
hemorrhage, but these are not the most likely causes of the presenting symptoms.
Rationale for Choice B:
Performing a vaginal examination is the most appropriate first action in this situation. This will allow the nurse to directly
assess the source and amount of bleeding, as well as to check for any retained placental fragments or cervical lacerations.
These findings could be the cause of the lochia rubra and clots, and prompt intervention may be necessary.
Rationale for Choice C:
While measuring the client's vital signs is an important part of the postpartum assessment, it is not the most immediate action
when there is evidence of active bleeding. Taking vital signs can be delayed while the nurse performs a vaginal examination to
assess the source and severity of the bleeding.
Rationale for Choice D:
Checking for a full bladder is not the most relevant action in this situation. A full bladder can contribute to postpartum
discomfort, but it is not likely to be the cause of the lochia rubra and clots. Addressing the bleeding should be the priority.
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