A nurse is assisting with the cane of a labor and delivery unit
The nurse is contacting the provider regarding the client's status. Which of the following findings should the nurse include in the report?
Select the 4 findings that the nurse should report
Gestational age
Vaginal examination
Uterine contractions
Maternal blood pressure
Correct Answer : A,C,E,F
A. Gestational age: The client is 31 weeks of gestation, which is preterm. This is critical information to determine the risk for preterm labor and guide interventions such as corticosteroid administration for fetal lung maturity or tocolytic therapy.
B. Vaginal examination: While a vaginal examination can provide information on cervical dilation and effacement, it is not appropriate to perform without consulting the provider first, especially in a preterm client with contractions.
C. Uterine contractions: The frequency (every 10 minutes) and duration (lasting 30 seconds) of contractions are critical findings that suggest the possibility of preterm labor. This information helps the provider decide on appropriate diagnostic or therapeutic measures, such as starting a tocolytic or performing fetal monitoring.
D. Maternal blood pressure: The maternal blood pressure is within normal limits (118/78 mmHg) and does not indicate a pressing concern in this scenario.
E. Maternal report of pain: The client reports cramping and low back pain, which could indicate preterm labor or another issue affecting uterine activity. This subjective information helps the provider assess the need for further evaluation or pain relief measures.
F. Fetal heart rate: The FHR is 140 beats per minute, which is within the normal range (110-160 bpm). A normal FHR suggests that the fetus is not in distress, but continuous monitoring and assessment are necessary to ensure the fetus remains well-oxygenated, especially in the context of uterine contractions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. It can cause medication given at later stages to be ineffective: This is incorrect; narcotic analgesics do not impact the effectiveness of later medications.
B. It will have no complications for the mother or infant: Narcotic analgesics can have side effects, including respiratory depression in the newborn.
C. It may result in respiratory depression to the newborn: Narcotics given close to delivery can depress the newborn’s respiratory efforts.
D. It will speed up the dilation and effacement: Narcotics do not affect the rate of cervical dilation or effacement.
Correct Answer is A
Explanation
A. Place the client in a lateral position: This improves uteroplacental perfusion and venous return, addressing hypotension.
B. Notify the provider: While necessary, it is not the first action.
C. Increase IV fluid rate: Fluid boluses can treat hypotension, but lateral positioning takes precedence.
D. Elevate the legs: This is helpful but secondary to lateral positioning.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.