A nurse is admitting a client who is at 38 weeks of gestation and is in the active phase of the first stage of labor. Which of the following assessment findings is the first priority for the nurse to report to the provider?

Contractions lasting 2 minutes and with no rest between contractions.

Pressure on the perineum causing the client to have the desire to bear down.

Discharge consisting of clear fluid from the vagina.

Passage of a bloodtinged mucous plug.

Answer and Explanation

The Correct Answer is A

Choice A: The first priority assessment finding to report to the provider is contractions lasting 2 minutes and with no rest between contractions. Prolonged contractions without adequate rest can lead to uterine hyperstimulation and fetal distress, potentially compromising the wellbeing of both the client and the baby. The provider needs to be informed immediately for further

evaluation and intervention.

Choice B: Pressure on the perineum and the desire to bear down indicate that the client is experiencing the urge to push, which is expected during the second stage of labor, not during the active phase of the first stage. It is not the first priority to report.

Choice C: Clear fluid discharge from the vagina can indicate rupture of membranes, but it is not an immediate concern unless the fluid is meconiumstained or there are other signs of fetal distress.

Choice D: Passage of a bloodtinged mucous plug (also known as "bloody show") is a common sign that labor is approaching, but it is not an immediate concern unless there are other signs of labor progression or complications. It is not the first priority to report.

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Correct Answer is A

Explanation

Choice A:The priority action when the fetal monitor tracing shows late decelerations after the client's membranes rupture is to turn the client onto her side. This position change helps relieve pressure on the vena cava and improves blood flow to the fetus.
Choice B: Increasing the client's IV fluid infusion rate is not the first priority in this situation, as late decelerations are primarily related to uteroplacental insufficiency rather than maternal hydration status.
Choice C: Administering oxygen to the client is important, but turning the client onto her side should be the first action to improve fetal oxygenation.
Choice D: Palpating the client's uterus is not the first priority in the presence of late

decelerations. The focus should be on relieving the compression on the vena cava and improving fetal oxygenation by changing the client's position.

A. Immediately report the situation to the client's provider and prepare the client for induction of labor. B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. C. Turn the client onto her left side. D. Offer the client a snack of orange juice and crackers

Correct Answer is D

Explanation

A. Immediately report the situation to the client's provider and prepare the client for induction of labor.This option is premature. The absence of fetal movement for 15 minutes during a nonstress test does not immediately indicate a need for induction of labor. Other less invasive interventions should be attempted first to stimulate fetal movement.

B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. While movement can sometimes stimulate fetal activity, removing the monitoring unit is not advisable during a nonstress test. Continuous monitoring is essential to accurately assess the fetal heart rate and movement.

C. Turn the client onto her left side.This position can improve uteroplacental blood flow and may help stimulate fetal movement. However, it is not the most effective initial intervention compared to offering a snack, which can provide a quicker response.

D. Offer the client a snack of orange juice and crackers.This is the correct intervention. The sugar in the orange juice can provide a quick source of energy to the fetus, potentially stimulating movement. Additionally, the act of eating can sometimes prompt fetal activity.

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A nurse is admitting a client who is at 38 weeks of gestation and is in the active phase of the first stage of labor. Which of the following assessment findings is the first priority for the nurse to report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform?

Correct Answer is D

Explanation

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