A nurse is caring for a 34-year-old female client in the labor and delivery unit.
The nurse reviews the findings for the client. Which findings are concerning and require intervention? Select All That Apply)
Blood pressure of 170/98 mm Hg
Pain rating of 5 out of 10 with each contraction
Variable decelerations lasting 20 seconds
Fetal heart rate of 142 beats/minute with accelerations
Deep tendon reflexes absent
Temperature of 98.6° F (37° C)
Correct Answer : A,C,E
Choice A rationale: A blood pressure of 170/98 mm Hg is significantly elevated and concerning during pregnancy. This may indicate preeclampsia, which requires immediate intervention to prevent complications for both the mother and the fetus.
Choice B rationale: A pain rating of 5 out of 10 with each contraction is common during labor and does not necessarily require intervention unless the pain is unmanageable or the client requests additional pain relief measures.
Choice C rationale: Variable decelerations lasting 20 seconds can indicate cord compression or other issues affecting fetal oxygenation. Continuous monitoring and possible interventions are required to ensure fetal well-being.
Choice D rationale: A fetal heart rate of 142 beats/minute with accelerations is a reassuring sign of fetal well-being. No immediate intervention is needed for this finding.
Choice E rationale: Absent deep tendon reflexes are a concerning finding, especially with the administration of magnesium sulfate. This can indicate magnesium toxicity, which requires prompt intervention to adjust the medication dosage and prevent adverse effects.
Choice F rationale: A temperature of 98.6° F (37° C) is within normal limits and does not require intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Being 37-weeks, 1-day gestation is considered term. This timing indicates the fetus is likely mature and ready for birth, which reduces the risk of complications compared to preterm delivery. However, early-term delivery can still have some associated risks, such as respiratory issues or feeding difficulties.
Choice B rationale
A pain rating of 5 during contractions is within the expected range during active labor. Pain management is an important aspect of labor care, but it does not inherently increase or decrease the risk of complications.
Choice C rationale
The vaginal exam findings of 4 cm dilation, 50% effacement, and -3 station indicate early labor progression. However, the negative station suggests the fetus is still high in the pelvis, which could pose a risk if labor stalls or if there is cephalopelvic disproportion.
Choice D rationale
Contractions every 3 to 4 minutes are consistent with active labor. Regular and moderate contractions are expected and necessary for labor to progress. This data point alone does not increase the risk for complications.
Choice E rationale
An A- blood type with Rh(D) immune globulin received at 28 weeks is managed appropriately to prevent Rh sensitization. Rh(D) immune globulin reduces the risk of hemolytic disease of the fetus and newborn in subsequent pregnancies, making it an important preventative measure but not a current risk factor. .
Correct Answer is B
Explanation
Choice B rationale
Providing multidisciplinary resources and ongoing support is crucial for newborns exposed to methadone. This approach helps in managing withdrawal symptoms and ensures the child receives comprehensive care.
Choice A rationale
Keeping the newborn in the nursery may be beneficial initially but does not address the long-term needs of the child and the family.
Choice C rationale
Administering methadone to the newborn is not typically done unless specifically indicated by the healthcare provider.
Choice D rationale
Calling social services for foster care placement may be necessary in some cases, but providing support and resources to the mother and child is the primary intervention.
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.