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. Fever and chills. B. Increased heart rate. C. Lower abdominal pain. D. Unusual vaginal discharge.

Correct Answer is A

Explanation

Choice A rationale:

Fever: A hallmark sign of inflammation, fever is a common and often early manifestation of endometritis. The body's

thermostat, located in the hypothalamus, is reset to a higher temperature in response to infection or inflammation. This

triggers a cascade of physiological events, including chills, shivering, and increased heat production, as the body attempts to

fight off pathogens. In endometritis, the fever is typically 100.4°F (38°C) or higher.

Chills: Often accompanying fever, chills are a sensation of coldness despite a normal or elevated body temperature. They result

from involuntary muscle contractions, which generate heat in an attempt to raise the body's temperature. Chills can be mild or

severe, and they often precede a rise in temperature.

Choice B rationale:

Increased heart rate: Tachycardia, or an increased heart rate, can occur in endometritis, but it is not a specific finding. It can be

present in various other conditions, including anxiety, pain, dehydration, anemia, and other infections. While it may be a sign

of endometritis, it's not considered a primary manifestation.

Choice C rationale:

Lower abdominal pain: Lower abdominal pain is a common symptom in postpartum women, but it is not always indicative of

endometritis. It can result from uterine contractions, incisional pain (if a cesarean section was performed), bladder distention,

constipation, or other postpartum complications. While it may be present in endometritis, it's not a specific finding.

Choice D rationale:

Unusual vaginal discharge: Lochia, the normal postpartum vaginal discharge, can vary in color and amount. However, unusual

vaginal discharge, such as foul-smelling or purulent discharge, can be a sign of endometritis. It's important to note that not all

women with endometritis will have abnormal discharge.

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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 collecting data from a patient who gave birth one week ago.Which of the following findings should the nurse identify as a manifestation of endometritis?

Correct Answer is A

Explanation

A home health care nurse is reinforcing teaching about breast engorgement with a client who is postpartum and is breastfeeding her newborn.Which of the following client statements indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client who is in labor about why epidural anesthesia is not initiated until a good labor pattern has been established.Which of the following explanations should the nurse include?

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?

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?

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 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 caring for a postpartum client who saturates a perineal pad in 10 min.Which of the following actions should the nurse take first?