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?
The client is experiencing preterm labor.
The nurse should administer prescribed medication and encourage bed rest.
The nurse should monitor contraction frequency and fetal heart rate.
The Correct Answer is B
Choice A is incorrect. Preterm labor is defined as uterine contractions that occur before 37 weeks of gestation. The
client in this case is at 38 weeks of gestation, which is considered term gestation. Therefore, preterm labor is not the
most likely condition the client is experiencing.
Rationale for Choice B
Choice B is partially correct. While bed rest may be recommended for some clients experiencing certain conditions
during pregnancy, it is not the most appropriate intervention for all clients at 38 weeks of gestation. Additionally,
administering medication without knowing the specific condition the client is experiencing is not safe or ethical.
Rationale for Choice C
Choice C is correct. Monitoring contraction frequency and fetal heart rate are two of the most important actions a
nurse can take to assess a client at 38 weeks of gestation. These parameters can provide valuable information about
the client's progress and help to identify any potential problems.
Explanation:
At 38 weeks of gestation, the client is considered to be at term. This means that she is full-term and her baby is ready
to be born. However, even at term, there are a number of conditions that can occur that may require nursing
intervention.
One of the most common conditions that can occur at term is labor. Labor is the process by which the uterus contracts
and dilates to push the baby out of the birth canal. The nurse should monitor the client for signs and symptoms of
labor, such as:
Regular contractions that are becoming stronger and closer together
Bloody show (mucus mixed with blood)
Rupture of membranes (breaking of water)
If the nurse suspects that the client is in labor, she should notify the healthcare provider immediately.
Another condition that can occur at term is preeclampsia. Preeclampsia is a serious condition that can cause high
blood pressure, protein in the urine, and swelling in the face, hands, and feet. If the nurse suspects that the client has
preeclampsia, she should monitor the client's blood pressure, protein levels in the urine, and weight. She should also
notify the healthcare provider immediately.
In addition to monitoring for these specific conditions, the nurse should also perform a general assessment of the
client's health. This includes taking the client's vital signs, checking her abdomen for fetal movement, and listening to
the baby's heartbeat.
By monitoring the client for signs and symptoms of these conditions, the nurse can help to ensure a safe and healthy
delivery for both the mother and the baby.
Therefore, the two most important actions the nurse should take are:
Monitor the client for signs and symptoms of labor and preeclampsia.
Perform a general assessment of the client's health.
The two most important parameters the nurse should monitor are:
Contraction frequency and intensity
Fetal heart rate
By following these steps, the nurse can provide the best possible care for the client and her baby.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A rationale:
Elevating the client's legs can improve venous return and cardiac output, but it does not directly address the underlying cause
of late decelerations, which is uteroplacental insufficiency.
While elevating the legs may have some benefit, it's not the most effective initial action to address late decelerations.
It's important to prioritize interventions that directly improve uteroplacental blood flow.
Choice C rationale:
Increasing the infusion rate of IV fluids can expand maternal blood volume, but it may not significantly improve uteroplacental
perfusion if there's underlying placental insufficiency.
It's not the most effective initial action to address late decelerations.
It may be considered as a secondary measure if repositioning doesn't resolve the decelerations.
Choice D rationale:
Administering oxygen via face mask can improve fetal oxygenation, but it does not directly address the underlying cause of
late decelerations, which is uteroplacental insufficiency.
It's not the most effective initial action to address late decelerations.
It may be considered as an adjunct measure to improve fetal oxygenation, but it's not a primary intervention for late
decelerations.
Choice B rationale:
Positioning the client on her side is the most effective initial action to address late decelerations because it:
Relieves pressure on the vena cava, which improves venous return and cardiac output.
Increases placental perfusion by increasing blood flow to the uterus.
This can help to correct fetal hypoxia and improve fetal heart rate patterns.
It's a simple, non-invasive intervention that can be quickly implemented and has a high success rate in resolving late
decelerations.
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