A nurse is caring for a female client in labor in the labor and delivery unit.
Complete the following Bowtie question by selecting 1 condition, 2 parameters to monitor, and 2 actions to take.
The Correct Answer is []
The client most likely has umbilical cord compression, as evidenced by the presence of variable decelerations in fetal heart rate (FHR) and uterine tenderness. Umbilical cord compression is the most plausible condition given the symptoms and clinical indicators. Variable decelerations in FHR often indicate transient umbilical cord compression. Uterine tenderness can be associated with positional changes that exacerbate compression. These findings necessitate immediate intervention to improve fetal oxygenation and monitor ongoing fetal well-being.
Parameters:
- Variable decelerations in FHR: Indicate intermittent cord compression, leading to changes in fetal oxygenation, necessitating continuous monitoring.
- Uterine tenderness: Suggests possible positional issues or complications related to compression, requiring careful assessment to ensure optimal fetal and maternal health.
Actions:
- Change client position: Positional changes can relieve pressure on the umbilical cord, improving fetal oxygenation.
- Initiate continuous fetal monitoring: Essential to assess the ongoing status of fetal heart rate and detect any further decelerations or complications promptly.
Other Conditions:
- Dysfunctional labor: Typically associated with abnormal progression of labor, not directly indicated by variable decelerations or uterine tenderness alone.
- Placental abruption: Characterized by painful bleeding and abdominal pain, not suggested by the provided data.
- Pre-eclampsia: Marked by high blood pressure and proteinuria, absent in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Blood pressure should be addressed first due to the client’s elevated BP (144/92 mmHg), which is a potential sign of complications such as preeclampsia.
Choice B rationale
Pulse of 99 bpm is slightly elevated but not immediately concerning compared to the high BP.
Choice C rationale
Respirations are within normal range (17/min) and do not require immediate intervention.
Choice D rationale
Temperature of 100.4°F (38.0°C) is slightly elevated but not as critical as the high BP.
Correct Answer is ["B","D","F"]
Explanation
Choice A rationale:
Supplementing with formula is not necessary based on the given information. The baby is voiding and passing stools adequately, indicating proper feeding. Instead, feeding on demand and ensuring frequent breastfeeding will help address any concerns about the baby's weight.
Choice B rationale:
Feeding 8 to 12 times per day and on demand is recommended to ensure adequate milk supply and proper growth and development of the newborn. Frequent feeding helps to establish and maintain milk production.
Choice C rationale:
Using plastic-lined breast pads is not recommended as they can trap moisture and create an environment that promotes nipple irritation and infection. It is better to use breathable, non-plastic-lined breast pads.
Choice D rationale:
It is correct that a newborn's stools should transition from the dark greenish color meconium to a yellow color within a few days as the baby begins digesting breast milk.
Choice E rationale:
Drinking more whole milk does not directly increase a mother's milk supply. Milk supply is primarily regulated by the frequency and efficiency of breastfeeding or pumping.
Choice F rationale:
Expecting the breasts to feel full, warm, and slightly tender when the milk comes in is accurate. This usually occurs around the third or fourth day postpartum and indicates that the milk production process is underway.
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