A nurse in the labor unit is admitting a patient who reports experiencing painful contractions.
The nurse determines that the contractions last 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 is the nurse’s priority action?
Have the patient void.
Ask the patient if she needs pain medication.
Turn the patient on her side and recheck the blood pressure.
Notify the healthcare provider of the findings.
The Correct Answer is C
Choice A rationale
Having the patient void is not the immediate priority. While it is important to ensure the bladder is not distended, which could interfere with labor progress, the vital signs suggest a more urgent concern.
Choice B rationale
Asking the patient if she needs pain medication is important for comfort measures during labor, but it is not the immediate priority. The nurse’s first responsibility is to ensure the safety of the mother and baby.
Choice C rationale
Turning the patient on her side and rechecking the blood pressure is the correct action. The maternal blood pressure is low, which could indicate supine hypotensive syndrome. This occurs when the gravid uterus compresses the inferior vena cava when the woman is supine, reducing venous return to the heart. Turning the woman on her side may relieve this pressure and improve blood pressure.
Choice D rationale
Notifying the healthcare provider of the findings is important, but it is not the first action the nurse should take. The nurse should first address the mother’s hypotension by turning her on her side.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale
Moving the client to a room closer to the nurses’ station is an appropriate action to address the safety needs of an older adult client who is becoming increasingly restless and intermittently confused. This allows for closer observation and quicker intervention if needed.
Correct Answer is C
Explanation
Choice A rationale
While followers demonstrating high critical thinking are valuable, passive contribution may not be as beneficial to a nurse leader’s performance. Active participation is often more beneficial in a healthcare setting, as it allows for the exchange of ideas and collaborative problem-solving.
Choice B rationale
Followers who are dependent and passive when they disagree may not contribute effectively to the team’s performance. Constructive disagreement can lead to better decision-making and innovation. Therefore, passive disagreement may not be the most beneficial trait for a nurse leader.
Choice C rationale
Followers who are active contributors and participate in developing and analyzing ideas are highly beneficial to a nurse leader’s performance. Active participation fosters a collaborative environment, encourages the exchange of ideas, and leads to innovative solutions. This type of follower can significantly enhance the performance of a nurse leader and the overall team.
Choice D rationale
While participation in developing and analyzing ideas is important, not being an active contributor can limit the effectiveness of this participation. Active contribution is key to fostering a collaborative and innovative environment.
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