A nurse is caring for a 28-year-old female client in the labor and delivery unit who is in the fourth stage of labor.A nurse is caring for a 28-year-old female client in the labor and delivery unit who is in the fourth stage of labor.
Complete the following sentence by using the list of options. The nurse should first monitor the client's
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
The nurse should prioritize monitoring the client's fundal tone followed by the client's blood pressure. Here's why:
- Fundal Tone: The client's fundus is boggy and not firming up with massage. This is a priority concern as it indicates uterine atony, which is a major cause of postpartum hemorrhage.
- Blood Pressure: Monitoring blood pressure is crucial as the client is experiencing heavy lochia, and a decrease in blood pressure can indicate hypovolemic shock due to blood loss.
So, the completed sentence would be:
- The nurse should first monitor the client's fundal tone followed by the client's blood pressure.
Taking care of immediate risks and stabilizing the patient is key in such cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Suctioning the mouth and nose ensures that the airway is clear of any meconium-stained fluid, which can cause respiratory issues in the newborn if inhaled.
Choice B rationale
While skin-to-skin contact is beneficial for bonding and temperature regulation, ensuring the airway is clear is a higher immediate priority.
Choice C rationale
Placing the newborn under a radiant warmer helps maintain body temperature but is secondary to ensuring the airway is clear of meconium-stained fluid.
Choice D rationale
Tactile stimulation is important for encouraging breathing, but first ensuring the airway is clear takes precedence.
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"}}
Explanation
Preterm Labor
Preterm labor refers to labor that begins before 37 weeks of gestation. The key findings associated with preterm labor are:
- Cervical effacement and dilation: The client is 100% effaced and 2 cm dilated.
- Regular uterine contractions: The client is experiencing contractions every 3 minutes, lasting 60 seconds.
- Bloody show: The presence of bloody mucus discharge is another sign of preterm labor.
- Low backache: The client reports cramping and low back pain.
Preterm Prelabor Rupture of Membranes (PPROM)
PPROM refers to the rupture of membranes before labor begins and before 37 weeks of gestation. The key findings associated with PPROM are:
- Vaginal discharge: The client reported urinary leakage earlier, which could be misinterpreted as amniotic fluid leakage. Clear mucus discharge can also be a sign of ruptured membranes.
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