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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The lecithin/sphingomyelin (L/S) ratio test is a crucial assessment of fetal lung maturity. Lecithin and sphingomyelin are phospholipids that are components of surfactant, a substance vital for reducing surface tension in the alveoli and preventing lung collapse at birth. A ratio of 2: or greater generally indicates adequate lung maturity.
Choice B rationale
The L/S ratio test does not assess the baby's blood type. Fetal blood typing is determined through other methods, such as cordocentesis or maternal blood tests for fetal DNA, if clinically indicated. The L/S ratio specifically evaluates the quantity and ratio of pulmonary surfactants.
Choice C rationale
This test does not check the baby's liver development. Fetal liver development is assessed through different parameters, such as ultrasound visualization of liver size, blood flow characteristics, and specific liver enzyme levels if a concern exists. The L/S ratio is solely focused on pulmonary maturity.
Choice D rationale
The L/S ratio test is not used to check for genetic disorders. Genetic disorders are identified through chromosomal analysis, DNA sequencing, or biochemical tests performed on amniotic fluid cells obtained during amniocentesis, or through chorionic villus sampling. The L/S ratio is a physiological marker of lung readiness.
Correct Answer is B
Explanation
Choice A rationale
Herpes simplex virus 2 (HSV-2) can be harmful to a developing fetus and newborn. While primary infection during the first trimester can rarely lead to congenital anomalies, the most significant risk is neonatal herpes, which occurs when the newborn is exposed to the virus during passage through the birth canal if active lesions are present. Neonatal herpes can cause severe, life-threatening complications.
Choice B rationale
Transmission of HSV-2 to the newborn is significantly higher if active genital lesions are present at the time of vaginal birth. The virus can be shed from these lesions and infect the infant as they pass through the birth canal. Therefore, a Cesarean section is typically recommended if active lesions are present at the onset of labor.
Choice C rationale
Wearing tight-fitting undergarments can increase moisture and friction, potentially irritating existing lesions and hindering healing. Loose-fitting cotton undergarments are generally recommended to allow air circulation and reduce irritation, promoting a more favorable environment for lesion resolution and comfort.
Choice D rationale
Antiviral medications, such as acyclovir, valacyclovir, or famciclovir, can help manage genital herpes by reducing the frequency, duration, and severity of outbreaks. They work by inhibiting viral replication. However, these medications do not cure the condition; HSV-2 remains a lifelong viral infection.
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