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 ["A","E"]

Explanation

Choice A rationale
A cesarean section will be necessary if vaginal lesions are present at the time of labor. This is to prevent the transmission of the herpes virus to the baby during delivery, which can lead to serious complications such as neonatal herpes, a potentially deadly infection.
Choice B rationale
While sitz baths can help alleviate the discomfort caused by genital herpes lesions, they do not directly protect the fetus from herpes infection. The primary purpose of sitz baths in this context is to provide symptomatic relief to the mother.

Choice C rationale
The newborn will not necessarily be observed and treated in the neonatal intensive care unit just because the mother has genital herpes. The need for neonatal intensive care would depend on various factors, including whether the baby contracts the virus during delivery.
Choice D rationale
Total abstinence from sexual intercourse is not necessary during the entire pregnancy. However, it is recommended to abstain from sexual intercourse during active outbreaks to reduce the risk of transmission.
Choice E rationale
Daily administration of Valacyclovir (Valtrex) is necessary after the 36th week of pregnancy. This is known as suppressive therapy, which can help reduce the risk of an outbreak at the time of delivery and thereby reduce the risk of transmitting the virus to the baby.

A. Expulsion of a blood-tinged mucous plug B. Pressure on the perineum causing the client to bear down C. Continuous contraction lasting 2 min D. Expulsion of clear fluid from the vagina

Correct Answer is C

Explanation

Continuous contractions lasting 2 minutes could indicate uterine tetany, which could lead to uterine rupture, a life-threatening situation that requires immediate medical attention.

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Naxlex Comprehensive Predictor Exams

A nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. What information should the nurse give to the client?

Correct Answer is ["A","E"]

Explanation

A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor, which of the following assessment findings should the nurse report to the provider first?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? (Select all that apply)

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is caring for a client who is experiencing a decrease in the fetal heart rate. Which of the following actions should the nurse take?

A nurse is providing preconception counseling for a client who is planning a pregnancy. Which of the following supplements should the nurse recommend to help prevent defects in the fetus?

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?

A nurse is examining a client who is in active labor and observes that the presenting part is in the left occiput posterior position. What is the clinical interpretation of this finding?

A nurse is caring for a client who is at 36 weeks of gestation and suspected of having placenta previa. Which of the following observations would support this diagnosis?