A nurse in a labor unit is admitting a patient who reports experiencing painful contractions. The nurse determines that the contractions last for 1 minute and occur every 3 minutes.The nurse records the following vital signs: fetal heart rate of 130/min, maternal heart rate of 128/min, and maternal blood pressure of 92/54 mm Hg. What should the nurse prioritize doing next?

Notify the provider of the findings.

Ask the patient if she needs pain medication.

Have the patient void.

Position the patient with one hip elevated.

Answer and Explanation

The Correct Answer is D

The correct answer is Choice D

Choice A rationale: Notifying the provider is important but not the first priority in this situation. The maternal hypotension (BP 92/54 mm Hg) and elevated maternal heart rate (128/min) suggest decreased perfusion, which can compromise uteroplacental blood flow. Immediate intervention is required before notifying the provider, especially if positioning can restore circulation and fetal oxygenation. Waiting to call without correcting the underlying cause may result in fetal distress or worsening maternal status.

Choice B rationale: While uncontrolled pain may contribute to elevated maternal heart rate, the hypotension and tachycardia suggest a more urgent hemodynamic imbalance. Pain management may become appropriate after stabilizing maternal circulation. Focusing on pain relief first delays essential interventions to improve perfusion, risking fetal compromise due to inadequate uteroplacental oxygen delivery. The fetal heart rate of 130/min is reassuring, but maternal circulation must be prioritized to sustain it.

Choice C rationale: A full bladder can contribute to uterine displacement, but there is no indication in the scenario that bladder distention is an issue. Voiding may be done later but does not address the immediate concern of maternal hypotension and compensatory tachycardia. Uteroplacental perfusion depends heavily on maternal blood pressure, and bladder status has secondary importance in the acute phase of circulatory compromise.

Choice D rationale: Elevating one hip improves venous return and cardiac output by relieving pressure on the inferior vena cava, which is compressed by the gravid uterus in the supine position. This correction reduces hypotension and restores uteroplacental perfusion. The maneuver is a first-line response for maternal hypotension in labor, helping stabilize both mother and fetus quickly. Fetal oxygen delivery depends on adequate maternal perfusion, which this position supports.

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Correct Answer is C

Explanation

Choice A rationale
Elevating the client’s legs is not the first action to take. While it can help with circulation, it does not directly address the issue of late decelerations.
Choice B rationale
Administering oxygen using a nonrebreather mask can be beneficial as it can increase the amount of oxygen available to the fetus. However, it is not the first action to take.
Choice C rationale
Placing the client in the lateral position is the correct action. This position can help improve placental blood flow and potentially improve the oxygen supply to the fetus.
Choice D rationale
Increasing the rate of maintenance IV infusion is not the first action to take. While it can help maintain hydration and blood pressure, it does not directly address the issue of late decelerations.

A. Cervical dilation. B. Amniotic fluid in the vaginal vault C. Report of pain above the umbilicus.

Correct Answer is A

Explanation

Choice A rationale
Cervical dilation is a positive sign of labor. During labor, the cervix dilates to allow the baby to pass through the birth canal. This is a definitive sign that labor is occurring.
Choice B rationale
Amniotic fluid in the vaginal vault could indicate rupture of membranes, but it does not confirm labor. Labor may or may not be present when the membranes rupture.
Choice C rationale
Pain above the umbilicus is not a typical sign of labor. Labor pain is usually felt in the lower back and lower abdomen.
Choice D rationale
Brownish vaginal discharge could be a sign of “bloody show,” which can occur as labor approaches. However, it does not confirm that labor is occurring.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and believes she is in labor. Which finding confirms to the nurse that the client is in labor?

Correct Answer is A

Explanation

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