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 D

Explanation

Choice A rationale:

The location of the fundus is not a reliable indicator of urinary retention. The fundus may be displaced upward by a full

bladder, but it can also be displaced by other factors such as uterine atony or a full rectum.

In the early postpartum period, the fundus is expected to be firm and around 1-2 fingerbreadths below the umbilicus. A fundus

that is three fingerbreadths above the umbilicus may be a sign of uterine atony, but it is not specifically indicative of urinary

retention.

Choice B rationale:

Blood pressure is not a specific indicator of urinary retention. A blood pressure of 130/84 mm Hg is within the normal range

for a postpartum client.

Elevated blood pressure could be due to various factors, such as pain, anxiety, or pre-existing hypertension. It is not a reliable

sign of urinary retention on its own.

Choice C rationale:

Lochia rubra is the normal postpartum discharge that consists of blood, mucus, and tissue debris. The amount of lochia rubra

is expected to decrease gradually over time. Moderate lochia rubra is a normal finding in a client who is 8 hours postpartum

and does not suggest urinary retention.

Choice D rationale:

Moderate swelling of the labia is a common finding in the postpartum period due to increased blood flow and fluid retention.

However, significant swelling of the labia can also be a sign of urinary retention.

When the bladder is full, it can press on the surrounding tissues, including the labia, causing them to swell. If the client is also

experiencing difficulty voiding or has a decreased urine output, the swelling of the labia may be a sign that she needs to

urinate.

A. Prepare for the delivery of the shoulders. B. Encourage the mother to rest between contractions. C. Check the mother’s blood pressure. D. Administer oxygen to the mother.

Correct Answer is A

Explanation

Choice A rationale:

Significance of retraction: Retraction of the fetal head against the maternal perineum is a crucial sign that the fetal shoulders

are about to be delivered. It indicates that the fetal head has fully descended into the pelvic outlet and is ready to rotate and

deliver the shoulders.

Urgency of preparation: It's essential for the nurse to promptly prepare for the delivery of the shoulders to ensure a safe and

timely birth:

Gather necessary equipment, including sterile gloves, towels, and possibly a suction bulb.

Position the mother appropriately, often in a semi-sitting or lithotomy position, to facilitate delivery.

Support the perineum to reduce tearing and guide the delivery of the shoulders.

Communicate with the mother to encourage effective pushing and maintain clear instructions throughout the process.

Anticipate potential complications, such as shoulder dystocia, and be prepared to assist with maneuvers to resolve it if

necessary.

Choice B rationale:

Rest during second stage: While rest is important during labor, encouraging rest between contractions at this specific point

(retraction of the head) could delay the delivery of the shoulders, potentially increasing risks for both mother and baby.

Maintaining momentum: The second stage of labor typically involves active pushing and uterine contractions to facilitate

delivery. Resting at this stage could interrupt the natural progression of labor.

Choice C rationale:

Role of blood pressure monitoring: Monitoring blood pressure is essential throughout labor to detect potential complications

like preeclampsia or hemorrhage. However, in this specific scenario, where the fetal head is already retracted and the

shoulders are imminent, preparing for delivery takes priority over routine blood pressure checks.

Choice D rationale:

Oxygen administration: Oxygen is sometimes administered during labor to support the mother's and baby's oxygen levels.

However, it's not a standard intervention for all laboring women, and its necessity would be based on individual assessments

and clinical judgment. In the absence of specific indications for oxygen, such as maternal distress or fetal heart rate concerns,

it's not the priority action when the fetal head is retracted and delivery of the shoulders is impending.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is 8 hours postpartum and multiparous.Which of the following findings should alert the nurse to the client’s need to urinate?

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who is in the second stage of labor.The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed. Which of the following actions should the nurse take?

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?

A nurse is caring for a client who has unrelieved episiotomy pain 8 hours following delivery. Which of the following actions should the nurse take?

A nurse is preparing to administer dinoprostone gel to a client who is pregnant. The client asks the nurse about the purpose of the medication.Which of the following responses should the nurse make?

A nurse is assisting with the care of a client who is at 7 cm of cervical dilation and 100% effacement, and in active labor.The client informs the nurse that she needs to push.Which of the following is the appropriate action for the nurse to take?

A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina.Which of the following actions should the nurse take first?

A nurse is assisting with the care of a client who is receiving Oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate the effectiveness of this medication?

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client’s perineal pad.Which of the following actions should the nurse take first?

A nurse is assisting in the care of a client who is at 38 weeks of gestation. 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?