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 C

Explanation

Choice A rationale:

Amniotic fluid in the vaginal vault may indicate that the client's membranes have ruptured, but it does not necessarily mean

that labor has begun. Some women experience rupture of membranes before labor starts, while others do not experience it

until labor is well underway.

Additionally, it is not always possible to visually confirm the presence of amniotic fluid, as it may be mixed with other fluids or

present in small amounts.

Therefore, the presence of amniotic fluid alone is not a definitive sign of labor.

Choice B rationale:

Contractions are a common sign of labor, but they can also occur for other reasons, such as Braxton Hicks contractions or a

urinary tract infection.

To be considered a sign of true labor, contractions should be regular, becoming progressively stronger, longer, and closer

together.

A frequency of every 3 to 4 minutes is often suggestive of labor, but it is not always definitive.

Some women may experience contractions that are less frequent or more irregular and still be in labor.

Choice C rationale:

Cervical dilation is the most reliable sign of labor.

During labor, the cervix gradually opens to allow the baby to pass through the birth canal.

Cervical dilation is typically measured in centimeters, with 10 centimeters being considered full dilation.

Once the cervix has dilated to 3-4 centimeters, it is generally considered to be active labor.

This is because dilation of this degree usually indicates that the contractions are strong enough to effectively move the baby

through the birth canal.

Choice D rationale:

Pain just above the navel, also known as suprapubic pain, can be a sign of labor, but it is not a definitive one.

This type of pain can also be caused by other factors, such as bladder fullness or indigestion.

Additionally, not all women experience pain in this area during labor.

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:

Retraction of the fetal head against the maternal perineum is a classic sign that the shoulders are about to be delivered. This is

known as the "turtle sign" because the fetal head appears to retract back into the body like a turtle's head.

It is important for the nurse to be prepared to assist with the delivery of the shoulders to ensure a safe and smooth delivery.

This includes:

Positioning the mother appropriately, such as in the McRoberts maneuver or a hands-and-knees position.

Applying gentle downward traction on the fetal head to help deliver the anterior shoulder.

Rotating the fetal shoulders as needed to facilitate delivery.

Monitoring the fetal heart rate closely for any signs of distress.

Choice B rationale:

While encouraging the mother to rest between contractions is important for conserving energy, it is not the priority action

when the fetal head is retracting. The nurse's focus should be on preparing for the delivery of the shoulders.

Choice C rationale:

Checking the mother's blood pressure is a routine part of labor and delivery care, but it is not specifically indicated when the

fetal head is retracting. There is no evidence to suggest that retraction of the fetal head is associated with changes in maternal

blood pressure.

Choice D rationale:

Administering oxygen to the mother may be helpful in some cases, such as if the fetal heart rate is showing signs of distress.

However, it is not the priority action when the fetal head is retracting. The focus should be on preparing for the delivery of the

shoulders.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting a nurse midwife in examining a client who is a primigravida at 42 weeks of gestation and states that she thinks she is in labor.Which of the following findings confirm that the client is in labor?

Correct Answer is C

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 providing care for a client who is in labor.The nurse notes variable decelerations on the fetal heart rate monitor. What could be the cause?

A nurse is caring for a client who is requesting to go to the bathroom immediately after a vaginal birth. Which of the following actions should the nurse take?

A nurse is assisting with the monitoring 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 is 14 hours postpartum.The nurse notes that the client’s breasts are soft, the fundus is firm and slightly deviated to the right, and the client’s pulse rate is 88/min with a respiratory rate of 18/min.Which of the following actions should the nurse take?

A nurse is collecting data from a postpartum client. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

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 client who has unrelieved episiotomy pain 8 hours following delivery. Which of the following actions should the nurse take?

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?