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.
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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Related Questions
Correct Answer is C
Explanation
A: Administering a 500 mL bolus of 5% dextrose in water is not necessary before the epidural administration, and it may not be recommended in active labor as it can increase the risk of fluid overload.
B: The duration of the anesthetic effect of the epidural can vary depending on the medication used, and it is not the nurse's priority during the preparation process.
C: Prior to administering epidural analgesia, the nurse should obtain a 30minute electronic fetal monitoring (EFM) strip to assess the fetal heart rate and monitor for any signs of fetal distress during the procedure.
D: Having the client stand very still with her arms at her side is not practical or necessary for epidural administration and could be uncomfortable for the client during labor.
Correct Answer is A
Explanation
A) Quickening: Quickening is the term used to describe the first perception of fetal movements by the pregnant woman. It typically occurs between 16 to 20 weeks of gestation, which aligns with the client's statement about feeling fluttering movements at 18 weeks.
B) Ballottement: Ballottement is a physical examination technique performed by a healthcare provider to assess the fetus's position in the uterus. It is not related to the client's perception of fetal movement.
C) Chloasma: Chloasma refers to hyperpigmented skin areas that can appear during pregnancy due to hormonal changes. It is not related to fetal movement.
D) Lightening: Lightening refers to the descent of the fetal head into the maternal pelvis, which typically occurs in the third trimester. It is not related to the feeling of fetal movements by the mother.
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