A nurse is assisting in the care of a client who is at 3 weeks of gestation. The client presents to the Labor and Delivery Unit in the early phase of active labor with contractions occurring every 3 to 4 minutes.

An 18-gauge needle is inserted in the left hand and oxytocin infusion is initiated.

An internal examination reveals a left occiput anterior (LOA) vertex, 4 cm dilation, complete effacement, and decelerations noted in the fetal heart rate (FHR) which decreases to 100/min with contractions, lasts 10 seconds, and returns to baseline within 20 seconds.

What condition is the client most likely experiencing, what are 2 actions the nurse should take to address that condition, and what are 2 parameters the nurse should monitor to assess the client’s progress?

The client is experiencing normal labor progression.

The nurse should continue monitoring contractions and fetal heart rate.

The nurse should ensure the client is comfortable and hydrated.

The nurse should monitor the client’s pain level and fluid intake

Answer and Explanation

Correct Answer : B,C

Choice A rationale:

While some of the client's findings are consistent with normal labor progression, the decelerations in the fetal heart rate (FHR) are concerning and indicate a potential problem. Normal labor progression would not typically involve FHR decelerations.

Choice B rationale:

Monitoring contractions and fetal heart rate: This is crucial to assess the client's labor progress and fetal well-being. The frequency, duration, and intensity of contractions, as well as the baseline FHR, variability, and presence of any decelerations, should be closely monitored. These parameters provide essential information about the adequacy of uterine contractions, fetal oxygenation, and potential need for interventions.

Choice C rationale:

Ensuring the client is comfortable and hydrated: Comfort measures can help the client cope with labor pain and anxiety, which can indirectly improve fetal oxygenation by reducing stress hormones. Hydration is essential for maintaining adequate blood flow to the placenta and fetus, supporting fetal well-being.

Choice D rationale:

While monitoring pain level and fluid intake is important, they are not the most immediate priorities in this situation. The priority is to address the potential fetal distress indicated by the FHR decelerations and ensure adequate uterine contractions and fetal oxygenation.

Additional notes:

The nurse should also notify the healthcare provider of the FHR decelerations and any other concerning findings.

Further interventions, such as changing the client's position, administering oxygen, or discontinuing the oxytocin infusion, may be necessary depending on the assessment findings and provider's orders.

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Correct Answer is A

Explanation

Choice A rationale:

When breastfeeding, it’s important for the baby to latch onto not just the nipple, but also some of the areola, which is the

darker circle of skin around the nipple. This allows the baby to get a deep latch, which is necessary for effective breastfeeding.

The baby’s chin should be firmly touching the breast, and their mouth should be wide open. When they attach, you should see

much more of the darker nipple skin above the baby’s top lip than below their bottom lip.

Choice B rationale:

While it’s true that babies have certain instincts when it comes to breastfeeding, they still need guidance and proper

positioning to latch correctly. Simply relying on the baby’s instincts may not ensure a proper latch, which could lead to

ineffective breastfeeding and potential discomfort for the mother.

Choice C rationale:

The size of the baby’s mouth does not determine how much of the nipple they should take in. Regardless of the size of the

baby’s mouth, they should still latch onto the nipple and some of the areola for effective breastfeeding. Taking only part of the

nipple could lead to a shallow latch, which can cause nipple pain and may not allow the baby to get enough milk.

Choice D rationale:

While it’s important for the baby to take in a good amount of the breast tissue, including the nipple and areola, during

breastfeeding, suggesting to include some breast tissue beyond the areola might be excessive. The key is to ensure a deep

latch, which typically involves the nipple and some of the areola, rather than the entire areola and additional breast tissue.

A. Contraction lasting 85 seconds B. Contraction resting period 35 seconds C. Heart rate 100/min for a 10-min period D. One contraction in a 10-min period

Correct Answer is A

Explanation

Choice A rationale:

Contraction duration: Contractions that last longer than 75 seconds are considered abnormal and should be reported to the

provider. This is because prolonged contractions can decrease oxygen supply to the fetus, leading to fetal distress.

Risk of uterine rupture: Excessively long contractions can also increase the risk of uterine rupture, a serious complication that

can endanger both the mother and the fetus.

Signs of fetal distress: The nurse should closely monitor the fetal heart rate for any signs of distress, such as late decelerations,

decreased variability, or bradycardia.

Need for intervention: If the contractions remain prolonged or if fetal distress is detected, the provider may need to intervene

to ensure the safety of both the mother and the fetus. This could involve measures such as administering medications to stop

or slow down labor, or performing a cesarean delivery.

Choice B rationale:

Contraction resting period: A contraction resting period of 35 seconds is within the normal range. Ideally, the resting period

between contractions should be at least 60 seconds, but it can vary. However, a resting period shorter than 30 seconds could

be a sign of tachysystole (excessively frequent contractions), which may also require intervention.

Choice C rationale:

Maternal heart rate: A maternal heart rate of 100 beats per minute is considered normal during labor. Heart rate can increase

with exertion, pain, and anxiety, which are common during labor. However, it's important to monitor for significant

tachycardia (heart rate over 120 beats per minute), which could indicate underlying issues such as dehydration or infection.

Choice D rationale:

Contraction frequency: One contraction in a 10-minute period is not indicative of active labor. Labor is typically defined as

having regular contractions that are 5 minutes apart or less, lasting for 45-60 seconds each, and causing progressive cervical

change. In early labor, contractions may be more sporadic and less intense.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby's mouth, which of the following responses by the nurse is appropriate?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who is in labor.Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

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