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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is choice B. Prolactin.

Choice A reason:

Estrogen. Estrogen is a hormone that plays a role in the development of the mammary glands and the ductal system during pregnancy. However, estrogen does not directly produce milk.

In fact, high levels of estrogen during pregnancy inhibit milk secretion by blocking prolactin. Therefore, estrogen is not the hormone necessary for milk production. • Choice B reason:

Prolactin. Prolactin is the hormone responsible for the production of breast milk. Prolactin is secreted by the pituitary gland in response to suckling or nipple stimulation. Prolactin levels rise during pregnancy and peak after delivery, when the sudden drop in estrogen and progesterone allows prolactin to take over and initiate lactation. Therefore, prolactin is the hormone necessary for milk production. • Choice C reason:

Progesterone. Progesterone is a hormone that also contributes to the development of the mammary glands and the alveoli during pregnancy. However, like estrogen, progesterone does not directly produce milk. Progesterone also inhibits milk secretion by blocking prolactin during pregnancy. Therefore, progesterone is not the hormone necessary for milk production. •

Choice D reason:

Lactogen. Lactogen is not a hormone, but a general term for any substance that stimulates lactation. There are different types of lactogens, such as human placental lactogen (hPL), which is produced by the placenta during pregnancy and has some lactogenic effects on the mammary glands. However, hPL is not the main hormone responsible for milk production. That role belongs to prolactin. Therefore, lactogen is not the hormone necessary for milk production.

A. chart the normal axillary temperature. B. recheck the infant's temperature rectally. C. place the infant in a radiant warmer. D. have the mother breastfeed the infant.

Correct Answer is C

Explanation

Choice A reason:

Charting the normal axillary temperature is not the priority in this situation. The infant's temperature is subnormal, indicating hypothermia, which requires immediate intervention.

Choice B reason:

Rechecking the infant's temperature rectally may provide a more accurate reading, but it is not the priority action at this moment. The infant's low temperature indicates the need for immediate warming to prevent further complications.

Choice C reason:

Placing the infant in a radiant warmer is the priority nursing action. The axillary temperature of 35.9°C (96.6°F) is below the normal range for a newborn, which is around 36.5-37.5°C (97.7-99.5°F). Hypothermia in newborns can be dangerous and lead to respiratory distress, metabolic problems, and other complications. A radiant warmer provides a controlled heat source to warm the infant and stabilize their body temperature.

Choice D reason:

Having the mother breastfeed the infant may help provide warmth and comfort, but it is not the priority action. The immediate concern is to raise the infant's body temperature to a safe range using a radiant warmer.

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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?

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Naxlex Comprehensive Predictor Exams

The student nurse learns that the hormone necessary for milk production is

Correct Answer is B

Explanation

An infant's axillary temperature is 35.9C (96.6F). The priority nursing action is to:

Correct Answer is C

Explanation

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