A nurse is caring for a client in active labor.
Admission Assessment.
0200:. Gravida 1, Para 0 at 39 weeks gestation.
Presents with.
contractions occurring every 5 to 6 min, 45 to 60 seconds.
duration.
Cervical examination 4 cm dilated, 50% effaced.
Admit.
to the labor and delivery unit.
Nurses' Notes.
0200:. Admitted to the labor and delivery unit, and reports pain as 7 on a scale.
of O to 10 with contractions.
Cervix 4 cm dilated, 50% effaced,with membranes intact.
0230:. The client reports increasing discomfort with contractions.
Cervix 5. cm dilated, 60% effaced, with membranes intact.
Contractions.
occurring every 5 min, 45 to 60 seconds duration.
0300:. Epidural anesthesia was initiated.
Cervix 7 cm dilated, 70% effaced,. with membranes intact.
Contractions occur every 4 to 5 min,60 seconds duration.
Vital Signs.
0200:. Temperature 36.9° C (98.4° F). Heart rate 86/min.
Respiratory rate 18/min.
BP 118/78 mm Hg. 0230:. Temperature 37° C (98.6° F). Heart rate 88/min.
Respiratory rate 20/min.
BP 120/80 mm Hg. 0300:. Temperature 37.1° C (98.8° F). Heart rate 90/min.
Respiratory rate 18/min.
BP 122/76 mm Hg. The nurse is assuming care for the client at 0305.
For each nursing action, click to specify if the nursing action is essential. contraindicated for the client.
Assess for urinary retention.
Encourage the client to turn from side to side.
Monitor for elevated temperature.
Inform the client to expect drowsiness.
Assist the client with ambulation.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"B"}}
No explanation
Correct Answer is D
Explanation
The correct answer is D. Contractions.
Choice A Reason: Hypertension Hypertension in pregnancy is a condition that can occur independently of an amniocentesis and is typically monitored throughout the pregnancy. It is characterized by a sustained high blood pressure of 140/90 mmHg or higher. While hypertension is a concern in pregnancy, it is not a direct complication of amniocentesis. Normal ranges for blood pressure in the third trimester are 101.6 to 143.5 mmHg systolic and 62.4 to 94.7 mmHg diastolic.
Choice B Reason: Vomiting Vomiting is not a typical complication following an amniocentesis. It may be associated with other conditions during pregnancy such as hyperemesis gravidarum or gastrointestinal disturbances but is not directly related to the procedure of amniocentesis.
Choice C Reason: Epigastric Pain Epigastric pain is typically associated with conditions like preeclampsia or other gastrointestinal issues in pregnancy, not with amniocentesis. It is characterized by pain in the upper abdomen and is not a common complication post-amniocentesis.
Choice D Reason: Contractions After an amniocentesis, especially at 33 weeks of gestation, monitoring for contractions is crucial because they can indicate preterm labor, which is a known risk associated with the procedure. The normal range for contractions would be none to infrequent Braxton-Hicks contractions, which are not regular and do not signify labor.
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