A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
Assist the client to turn onto her side.
Prepare for an immediate vaginal delivery.
Prepare for a cesarean birth.
Assist the client to an upright position.
The Correct Answer is A
Assist the client to turn onto her side. This is the correct answer because turning the client onto her side can improve blood flow to the placenta and increase fetal oxygenation. Hypotension is a common cause of decreased uteroplacental perfusion, which can lead to fetal distress and late decelerations on the fetal monitor. The nurse should also administer oxygen, increase IV fluids, and notify the provider. • Choice B reason:
Prepare for an immediate vaginal delivery. This is not the correct answer because there is no indication that the client is ready for delivery. The client has 6 cm of cervical dilation, which means she is still in the active phase of labor. The second stage of labor begins when the cervix is fully dilated (10 cm) and ends with delivery of the baby. Preparing for an immediate vaginal delivery would not address the cause of hypotension or improve fetal oxygenation. • Choice C reason:
Prepare for a cesarean birth. This is not the correct answer because there is no indication that the client needs a cesarean birth. A cesarean birth may be indicated if there are signs of fetal compromise, such as severe variable or late decelerations, or maternal complications, such as placenta previa or cord prolapse. However, these conditions are not present in this scenario. Preparing for a cesarean birth would not address the cause of hypotension or improve fetal oxygenation. • Choice D reason:
Assist the client to an upright position. This is not the correct answer because placing the client in an upright position can worsen hypotension and decrease uteroplacental perfusion. An upright position can increase pressure on the inferior vena cava and reduce venous return to the heart. This can lower cardiac output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Rupture of the membranes is not a reliable sign of true labor, as it can occur before or during labor, or be artificially induced by the provider. • Choice B reason:
Patterns of contractions can vary depending on the stage and phase of labor, and can also be influenced by factors such as hydration, activity, and medication. Contractions alone do not indicate true labor unless they are accompanied by cervical changes. • Choice C reason:
Changes in the cervix, such as effacement (thinning) and dilation (opening), are the most accurate indication of true labor. Cervical changes are caused by the pressure of the presenting part and the force of the contractions. The nurse should assess the cervix periodically to determine the progress of labor. • Choice D reason:
The station of the presenting part refers to the relationship of the fetal head to the maternal ischial spines, which are bony landmarks in the pelvis. The station can range from -5 (high) to +5 (low), with 0 being at the level of the ischial spines. Station does not indicate true labor, as it can vary depending on the parity, pelvic shape, and fetal position of the client.
Correct Answer is B
Explanation
Choice A reason:
Choice A is incorrect because an Apgar score of 7 would not be appropriate for the described condition. An Apgar score of 7-10 is considered normal for a baby at 1 minute after birth. This baby shows positive signs such as a heart rate of 138 bpm, loud vigorous crying, spontaneous movement and flexion of the extremities, and pink skin color except for a bluish color of the hands and feet, which indicate good overall health.
Choice B reason:
Choice B is the correct answer. An Apgar score of 8 is appropriate for the described condition.
The Apgar score evaluates the baby's condition at 1 minute after birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each criterion is scored from 0 to 2, and the scores are summed up to determine the overall Apgar score. In this case, the baby exhibits positive signs in most of the criteria, resulting in an Apgar score of 8.
Choice C reason:
Choice C is incorrect because an Apgar score of 9 would be too high for the baby's condition. While the baby is exhibiting positive signs, there are still some concerns such as the bluish color of the hands and feet, which may indicate some minor circulation issues.
Choice D reason:
Choice D is also incorrect because an Apgar score of 10 is the highest possible score, and it is typically given to babies who exhibit absolutely no signs of distress or health issues at 1 minute after birth. While this baby shows mostly positive signs, the bluish color of the hands and feet suggests that there might be some minor health concerns, justifying an Apgar score of 8.
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.