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 A
Explanation
Choice A rationale
If a client is comfortable with the care they receive, they are indeed more likely to continue to seek treatment. Cultural competence in healthcare can help ensure that all patients, including those from underrepresented cultures, feel comfortable and understood. This can lead to increased patient engagement and better health outcomes.
Choice B rationale
While it’s true that without culturally competent care, a client might face financial barriers to treatment, it’s not a direct benefit of culturally competent care. The main benefits of culturally competent care are improved patient satisfaction, better health outcomes, and increased patient safety.
Choice C rationale
While receiving culturally competent care can have many benefits, reducing the chance that the client will need psychotropic medications is not directly related to cultural competence. The need for such medications is determined by a client’s specific health needs.
Choice D rationale
Providing culturally competent care can indeed help reduce a client’s fear of risking relationships and jobs by seeking care. By respecting and understanding a client’s cultural background, healthcare providers can help alleviate fears and misconceptions about seeking care. PregnancyPregnancy Explore
Correct Answer is C
Explanation
Choice A rationale
It is not recommended to increase weight-bearing exercises during pregnancy. Weight-bearing exercises can put additional stress on the joints, which are already under strain due to the increased weight and changes in body shape during pregnancy.
Choice B rationale
It is not necessary to refrain from exercises that include stretching during pregnancy. In fact, gentle stretching can be beneficial to help alleviate some common discomforts of pregnancy such as backache and leg cramps.
Choice C rationale
Moderate exercise does improve circulation. Improved circulation can help reduce swelling, varicose veins, and feelings of fatigue, which are common during pregnancy.
Choice D rationale
It is not necessary to rest for 30 minutes before each new exercise. However, pregnant women should listen to their bodies and rest if they feel tired.
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