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A nurse is caring for a client at 39 weeks gestation

Exhibits
Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again.

Vital Signs

1130

Oral temperature 38.3 C (101 F )

Heart rate 98min

Respiratory rate 18/min

Blood pressure 112/59 mm Hg 

Oxygen saturation 98% on room air

Nurses Notes

1130

Client states, ‘I think my water broke. The pad under me is soaked’. Clear fluid noted on pad. Nitrazine positive. Uterine contractions every 3 mins moderate to palpation. Fetal heart rate is 140/min.

Diagnostic Results

1200

HGB 10 g/dl (greater than 11 g/dl)

HCT 34% (greater that 33%)

WBC 22,000 ( 5,000 – 11,000)

A.

Oral temperature 38.3 C (101 F )

B.

HGB 10 g/dl (greater than 11 g/dl)

C.

Heart rate 98min

D.

Blood pressure 110/60 mm Hg

E.

Uterine contractions every 3 mins moderate to palpation

Answer and Explanation

The Correct Answer is ["A","B"]

  • Oral temperature 38.3°C (101°F)
    Elevated temperature indicates maternal fever, which could suggest infection such as chorioamnionitis, especially concerning with ruptured membranes.
  • HGB 10 g/dL (normal > 11 g/dL)
    Low hemoglobin indicates anemia, which could compromise oxygen delivery to the fetus and affect maternal health during labor.

Explanation for non-highlighted findings:

  • Heart rate 98/min: Slightly elevated but within normal range for labor.
  • Blood pressure 112/59 mm Hg: Normal blood pressure for pregnancy.
  • Uterine contractions every 3 mins moderate to palpation: Normal pattern for active labor.


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Related Questions

Correct Answer is C

Explanation

A. Catheterization may be necessary if the client cannot void but is not the first step before ambulation.
B. Evaluating deep tendon reflexes is more relevant for clients receiving magnesium sulfate, not primarily for epidural assessment.
C. Assessing motor function of the lower extremities ensures the client has adequate strength and sensation to safely ambulate after an epidural.
D. Administering meperidine is for pain management and does not relate to safety before ambulation.

Correct Answer is D

Explanation

A. An amniotic fluid index (AFI) less than 5 cm indicates oligohydramnios and potential fetal compromise.
B. Fetal limb movements fewer than 3 in 30 minutes may be concerning; however, 4 movements suggest some activity but must be assessed with other parameters.
C. A nonreactive nonstress test suggests fetal distress or lack of fetal well-being.
D. Sustained fetal breathing movements of at least 20 seconds in 30 minutes indicate good fetal neurologic function and well-being.

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