A nurse has just received a shift report on their assigned labor clients.
Which of the following clients should be seen first?
A client with a fetal heart rate of 110 beats per minute with moderate variability and accelerations.
A client with an epidural who is 7 cm dilated.
A client with a blood pressure of 110/82 mmHg, heart rate of 80 beats per minute, and oxygen saturation of 98%.
A client with a fetal heart rate baseline of 130s, minimal variability, and late decelerations.
The Correct Answer is D
Choice A rationale
A fetal heart rate (FHR) of 110 beats per minute with moderate variability and accelerations is within the normal range (110-160 bpm). Moderate variability indicates a healthy, well-oxygenated fetus, and accelerations are reassuring signs. This client is stable and does not require immediate intervention.
Choice B rationale
A client with an epidural who is 7 cm dilated is stable. The nurse should continue to monitor the client's progress and vital signs, but there is no indication of immediate distress. The epidural can cause a slight decrease in blood pressure, which would require monitoring but not an urgent response.
Choice C rationale
A blood pressure of 110/82 mmHg, heart rate of 80 beats per minute, and oxygen saturation of 98% are all within normal ranges. This client is stable and does not have any signs of distress. The nurse should continue to monitor the client but does not need to see them first.
Choice D rationale
A fetal heart rate baseline of 130s is normal, but minimal variability and late decelerations are non-reassuring signs. Minimal variability (less than 6 beats per minute) indicates a potential lack of fetal oxygenation, while late decelerations are a sign of uteroplacental insufficiency. This requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While administering analgesics is a crucial step in managing a vaso-occlusive crisis due to severe pain, it is not the first intervention. The client's report of a severe headache with blurry vision, particularly in the context of sickle cell disease, is a sentinel symptom. These neurological signs can indicate a central nervous system complication, such as a stroke, which requires immediate neurological assessment before any other interventions.
Choice B rationale
In a vaso-occlusive crisis, a severe headache and blurry vision are neurological red flags. These symptoms suggest potential cerebral hypoxia or infarction, which could be a prelude to a stroke. Assessing the client's neurological status is the first priority to establish a baseline and determine the extent of the neurological deficit. This rapid assessment guides subsequent life-saving interventions.
Choice C rationale
Increasing intravenous fluids is a standard component of vaso-occlusive crisis management to promote hemodilution and improve blood flow. However, it is not the first action in this specific scenario. The client's presenting symptoms of headache and blurry vision point to a potential neurological emergency that requires immediate assessment to rule out or confirm a stroke, which takes precedence over general fluid management.
Choice D rationale
Administering oxygen is beneficial in a vaso-occlusive crisis to address tissue hypoxia. However, it is not the immediate first action given the client's specific neurological symptoms. Oxygen saturation is typically maintained above 95% in these patients. The priority is to assess the client's neurological status to rapidly identify a potentially life-threatening stroke, which dictates the immediate course of action.
Correct Answer is C
Explanation
Choice A rationale
A station of +1 cm indicates the presenting part is below the ischial spines. The ischial spines are the anatomical landmark used to determine station. A measurement of +1 cm signifies a descent of 1 cm past this landmark, not above it. A measurement of -1 cm would be 1 cm above the ischial spines.
Choice B rationale
The station is at 0 when the presenting part is at the level of the ischial spines. This indicates that the widest part of the fetal head has passed through the pelvic inlet and is now engaged. A station of +1 is a further descent past this point, not at the same level.
Choice C rationale
A station of +1 means the presenting part, in this case, the vertex, has descended 1 cm past the level of the ischial spines. The ischial spines are the narrowest part of the pelvis, and a positive station indicates fetal descent through this point and into the midpelvis, which is a progression of labor.
Choice D rationale
The presenting part entering the pelvic inlet is typically associated with a station of -2 or -3, prior to engagement. A station of +1 means the fetus is well past the inlet and has descended through the midpelvis, indicating that engagement has already occurred.
Choice E rationale
The presenting part is on the perineum at a much lower station, typically a +4 or +5, which is when crowning occurs. A station of +1 indicates that the presenting part is in the midpelvis, still needing to descend further before reaching the perineum for delivery.
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