A nurse is caring for a 26-year-old female client in the labor and delivery unit. The client is gravida 2, para 1, term 1, living 1, and is admitted with cervical dilation of 4 cm, 70% effacement, and -1 station. The pregnancy has been uncomplicated.

Exhibits:

Exhibits

The nurse reviews the client data. Drag the word choices to complete the sentence.
Abnormal FHR patterns can result in
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,
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, and
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.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"E"}

Acidemia: Acidemia refers to an abnormal acidity in the blood (pH < 7.35). Prolonged abnormal FHR patterns can indicate insufficient oxygen delivery to the fetus, leading to anaerobic metabolism and the production of lactic acid, causing acidemia. The normal fetal pH is around 7.30-7.35.

Hypoxemia: Hypoxemia is a reduced level of oxygen in the blood. Abnormal FHR patterns may signal that the fetus is not receiving adequate oxygen, potentially due to cord compression, placental insufficiency, or other factors affecting oxygen transfer. Normal oxygen saturation for a fetus is generally around 30-70%.

Hypoxia: Hypoxia is a condition where there is insufficient oxygen available to meet the metabolic needs of the fetus. Abnormal FHR patterns can indicate ongoing or impending hypoxia, which can lead to severe fetal distress and compromise. It is crucial to monitor and address such conditions promptly.

Rationale for Incorrect Answers:

Hypoglycemia: Hypoglycemia refers to low blood glucose levels (typically < 45 mg/dL in newborns). Abnormal FHR patterns are not directly associated with changes in glucose metabolism. Rather, hypoglycemia in neonates is often related to maternal diabetes, prematurity, or other metabolic disturbances.

Meconium Stool: Meconium-stained amniotic fluid is a possible indicator of fetal distress but is not a direct result of abnormal FHR patterns. Meconium passage may be associated with post-term pregnancy, fetal hypoxia, or other factors, but the direct consequences of abnormal FHR patterns are more specifically related to oxygenation and acid-base status.

Maternal Hypotension: Maternal hypotension, or low blood pressure (typically < 90/60 mm Hg), is a maternal condition that can affect fetal well-being if severe and prolonged. However, it is not a direct result of abnormal FHR patterns. Instead, maternal hypotension can contribute to abnormal FHR by impairing uteroplacental perfusion.

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Correct Answer is B

Explanation

Choice A rationale

Notifying the nursery about the client’s response is not an immediate intervention. It is more important to manage uterine contractions and fetal oxygenation before informing other departments about the client's condition.

Choice B rationale

Restarting the oxytocin infusion rate per protocol is necessary to resume labor induction. Oxytocin increases uterine contractions, promoting cervical dilation and progression of labor. Continuous monitoring is required to adjust the dosage.

Choice C rationale

Stopping oxygen per cannula is not recommended if fetal distress is present. Oxygen supplementation ensures adequate fetal oxygenation during uterine contractions, reducing the risk of hypoxia and related complications.

Choice D rationale

Checking for clonus in both feet is not relevant to the current scenario. Clonus is a neurological sign indicating hyperreflexia, often unrelated to labor management. The focus should be on managing uterine contractions and fetal well-being.

A. Evaluate fetal heart rate and contraction patterns. B. Obtain prescription to repeat hepatic panel. C. Monitor for evidence of seizure activity. D. Check the urinary output in hourly urinometer. E. Inspect the perineum for vaginal bleeding.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale

Evaluating fetal heart rate and contraction patterns is critical as magnesium sulfate can impact uterine activity and fetal well-being. Monitoring ensures timely intervention if abnormalities in fetal status or labor progression are detected.

Choice B rationale

Obtaining a prescription to repeat the hepatic panel is necessary to monitor liver function, especially if there is a suspicion of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count) which complicates severe preeclampsia.

Choice C rationale

Monitoring for evidence of seizure activity is crucial as the patient is receiving magnesium sulfate for eclampsia prophylaxis. Close observation helps in early detection and management of any seizure episodes, preventing complications.

Choice D rationale

Checking urinary output in an hourly urinometer is essential to assess renal function, as preeclampsia and magnesium sulfate can affect renal perfusion and output. Monitoring ensures timely intervention if there is a decline in output.

Choice E rationale

Inspecting the perineum for vaginal bleeding is less immediately relevant unless there is a concern for placental abruption or other obstetric complications. Focus on maternal systemic symptoms and fetal monitoring is more critical initially.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client receiving a solution of magnesium sulfate suddenly develops right upper quadrant pain. After reviewing abnormal laboratory results, what action should the nurse implement? (Select all that apply)

Correct Answer is ["A","B","C","D"]

Explanation

The nurse knows that hydralazine, while magnesium sulfate will help prevent seizures, will help decrease blood pressure thus?

A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?

The nurse reports the current assessment findings to the healthcare provider (HCP). Based on the assessment findings, the priority diagnosis suspected is preeclampsia. This diagnosis places the client at risk of which complications?

Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

Following an amniocentesis, a client verbalizes several concerns. Which reported finding indicates to the nurse that the client is experiencing a complication from the amniocentesis?

Assessment findings of a 4-hour-old newborn include murmur, irregular respiratory rate at 64 breaths/min, heart rate of 150 beats/min with soft murmur, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?