A nurse is assisting in evaluating a client's progress during labor.
Click to highlight the client findings that indicate the labor is progressing as expected. To deselect a finding, click on the finding again.
Nurses' Notes
1615:
Client is in the partial sitting position and is instructed to bear down during uterine contraction. Client reports the urge to defecate. There is increased bloody show and the cervix is 10 cm dilated. Contractions 5 min apart. Contractions strong on palpation.
Vital Signs
1615:
Temperature 39.1° C (102.4" F)
Respiratory rate 20/min
Heart rate 110/min
Blood pressure 100/74 mm Hg
Oxygen saturation 96%
Client reports the urge to defecate
There is increased bloody show
cervix is 10 cm dilated
Contractions strong on palpation
Temperature 39.1° C (102.4" F)
Heart rate 110/min
The Correct Answer is ["A","B","C","D"]
Rationale for Correct Options:
- Urge to defecate occurs as the fetal head descends further into the birth canal, putting pressure on the rectum and perineum. This is a common sign of the second stage of labor, indicating that the client is nearing delivery.
- Increased bloody show results from cervical dilation and effacement as the capillaries in the cervix rupture. A greater amount of blood-tinged mucus is expected as labor progresses, particularly in the transition phase and early second stage.
- Cervix 10 cm dilated confirms that the client has reached full cervical dilation, which is required for the second stage of labor to begin. Complete dilation allows for the passage of the fetus through the birth canal.
- Contractions strong on palpation indicate effective uterine activity, which is necessary for fetal descent and expulsion. Strong contractions help in moving the baby downward and increasing pressure on the cervix.
Rationale for Incorrect Options:
- A heart rate of 110/min is elevated compared to the client’s earlier readings (90/min at 0830, 110/min at 0845) and may indicate maternal stress or exertion from labor pain. While mild increases in maternal heart rate are expected during labor, tachycardia above 110/min warrants further evaluation, particularly in the presence of fever.
- Temperature of 39.1°C (102.4°F). This temperature is abnormally high and suggests infection, such as chorioamnionitis, especially considering the prolonged rupture of membranes since 1900 the previous night. Normal maternal temperature may rise slightly during labor due to exertion, but fever above 38°C (100.4°F) is concerning and requires medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Use the arms to pick up heavy items. Lifting heavy objects using only the arms increases strain on the back, worsening pain. Pregnant clients should bend at the knees and lift with their legs while keeping the back straight to reduce stress on the lumbar region.
B. Raise chairs to keep knees lower than hips. Sitting with knees lower than the hips can worsen lumbar lordosis, increasing back discomfort. Instead, knees should be at or slightly above hip level to maintain spinal alignment and reduce strain on the lower back.
C. Perform pelvic rocking exercises several times per day. Pelvic rocking strengthens and stretches lower back muscles, improving flexibility and reducing discomfort. This exercise helps alleviate strain from the growing uterus and supports better posture, decreasing back pain.
D. Sit in a hot tub for 30 min every evening. Prolonged exposure to high temperatures, such as in a hot tub, can cause maternal hyperthermia, increasing the risk of fetal neural tube defects. Warm baths are a safer option to relieve muscle tension without harmful effects.
Correct Answer is B
Explanation
A. Oxytocin. This medication is typically administered intravenously or intramuscularly to promote uterine contractions and control postpartum hemorrhage. It is not given via the sublingual or rectal route.
B. Misoprostol. This prostaglandin analog is effective in managing postpartum hemorrhage by stimulating uterine contractions. It can be administered via several routes, including oral, sublingual, and rectal, making it a versatile option in hemorrhage control. The rectal route is often preferred in emergencies due to rapid absorption and minimal gastrointestinal side effects.
C. Carboprost. This medication is a prostaglandin used to treat postpartum hemorrhage but is administered intramuscularly rather than sublingually or rectally. It is typically reserved for cases that do not respond to first-line treatments due to its potential for significant gastrointestinal and cardiovascular side effects.
D. Methylergonovine. This ergot alkaloid is effective in reducing postpartum hemorrhage by inducing strong uterine contractions. However, it is administered intramuscularly or orally and is contraindicated in clients with hypertension due to its vasoconstrictive properties.
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