A nurse is caring for a client in labor who has an epidural in place and is on continuous internal monitoring with a fetal scalp electrode and intrauterine pressure catheter.

The nurse notes a strong contraction on the monitor and the client reports nausea accompanied by an urgent need to have a bowel movement.

Which of the following assessments is the nurse's highest priority?

Determine the client's temperature, heart rate, and blood pressure.

Determine the fetal heart rate in relationship to the contraction.

Examine the vaginal discharge for the presence of meconium.

Perform a vaginal examination to assess labor progress.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While monitoring vital signs (temperature, heart rate, and blood pressure) is important for overall maternal assessment, in the context of strong contractions and reported nausea/urge to defecate, these specific vital signs are not the immediate priority for identifying the most critical complication. Normal temperature is 36.5-37.5°C, heart rate 60-100 bpm, blood pressure 90/60 to 120/80 mmHg.

Choice B rationale

The client's symptoms (strong contraction, nausea, urge to defecate) strongly suggest the second stage of labor, specifically an urge to push. The highest priority is to determine the fetal heart rate in relationship to the contraction, as this immediate assessment evaluates fetal well-being and detects potential distress, like late decelerations, indicating uteroplacental insufficiency.

Choice C rationale

Examining vaginal discharge for meconium is important if there are signs of fetal distress, but assessing the fetal heart rate pattern in relation to contractions directly provides real-time information about fetal oxygenation and is therefore the immediate priority when assessing labor progress with these symptoms.

Choice D rationale

Performing a vaginal examination to assess labor progress is a crucial step to confirm cervical dilation and fetal descent. However, before internal examination, ensuring fetal well-being through external monitoring of the fetal heart rate during contractions is paramount, especially with the client's reported symptoms suggesting advanced labor.

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Correct Answer is D

Explanation

Choice A rationale

900 mL of urine output since birth (9 hours postpartum) translates to an average of 100 mL/hour. A normal urine output is typically 0.5 to 1 mL/kg/hour, which is usually greater than 30 mL/hour for adults. This indicates adequate renal perfusion and fluid balance rather than deficit.

Choice B rationale

A temperature of 37.6° C (99.6° F) is considered a low-grade fever. While it could be an early sign of infection, it is not a direct indicator of fluid volume deficit. Normal postpartum temperature may slightly increase due to dehydration or exertion during labor but usually remains below 38°C (100.4°F).

Choice C rationale

Reports of excessive sweating could be a compensatory mechanism for fever or a response to hormonal changes postpartum, but it is not a primary indicator of fluid volume deficit. In fact, excessive sweating can contribute to fluid loss, but it is not the most definitive sign.

Choice D rationale

A blood pressure of 80/55 mm Hg, particularly with a quantitative blood loss of 1200 mL, is a significant indicator of fluid volume deficit, specifically hypovolemic shock. Normal postpartum blood pressure is usually similar to pre-pregnancy levels (e.g., 90/60 to 120/80 mmHg). The low blood pressure reflects inadequate circulatory volume compromising tissue perfusion.

A. Hematocrit 37% (37% to 47%). B. Creatinine 0.9 mg/dL (0.5 to 1 mg/dL). C. WBC count 11,000/mm (5,000 to 10,000/mm). D. Fasting blood glucose 180 mg/dL (74 to 106 mg/dL).

Correct Answer is D

Explanation

Choice A rationale

A hematocrit of 37% falls within the normal physiological range for a pregnant individual, which typically expands due to increased plasma volume. This hemodilution is a normal adaptive response to pregnancy, ensuring adequate perfusion to the placenta and fetal unit. This finding does not warrant reporting as it reflects a healthy maternal circulatory adjustment.

Choice B rationale

A creatinine level of 0.9 mg/dL is within the normal reference range for renal function in pregnant individuals. Glomerular filtration rate (GFR) increases during pregnancy, leading to a slight decrease in serum creatinine. This value indicates appropriate renal clearance and is not a cause for concern.

Choice C rationale

A WBC count of 11,000/mm³ is generally considered within the physiological elevation often seen during pregnancy, particularly in the second and third trimesters. This mild leukocytosis is an immunological adaptation, supporting the maternal immune response without indicating an infectious process or pathology that requires immediate reporting.

Choice D rationale

A fasting blood glucose of 180 mg/dL is significantly elevated above the normal range (74 to 106 mg/dL) and indicates hyperglycemia. This finding is highly suggestive of gestational diabetes mellitus, which can lead to adverse maternal and fetal outcomes if not managed. Therefore, it requires immediate reporting to the provider for further evaluation and intervention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 9 hours postpartum following a cesarean birth with a quantitative blood loss of 1200 mL. Which of the following findings indicates the client is experiencing a fluid volume deficit?

Correct Answer is D

Explanation

A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is caring for a female client, age 30, at 37 weeks of gestation, admitted to the labor and delivery unit from the provider’s office for observation and laboratory testing. Which of the following assessment findings should the nurse report to the provider?

A nurse is providing teaching with an antepartum client who has a new diagnosis of genital herpes simplex virus 2 (HSV-2). Which of the following information should the nurse include?

A nurse is caring for a female client, age 30, at 37 weeks of gestation in the labor and delivery unit for blood pressure observation. After reviewing the client’s electronic health record, the nurse should identify that the client is at risk for developing which of the following complications?

A nurse is performing a nutritional assessment for a client during their first prenatal visit at 12 weeks of gestation. Which of the following findings indicates that the client should be referred to a registered dietician?

A nurse is caring for a postpartum client who recently had an indwelling urinary catheter removed. Which of the following findings indicates that the client is able to void effectively?

A nurse is teaching the parents of a newborn about the critical congenital heart disease screening. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a newborn in the neonatal unit following delivery. Complete the following sentence by using the list of options. The nurse should further evaluate ________ and ________ to determine if the newborn is experiencing a complication.

A nurse is caring for a client who is experiencing severe pain during active labor. Which of the following medications should the nurse plan to administer and document in the client's medical record?