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 D
Explanation
Choice A rationale
External fetal monitors are non-invasive and do not pose a risk of transmitting HIV from mother to baby. They are considered safe for monitoring fetal well-being in an HIV-positive mother.
Choice B rationale
Administering antiviral medication is essential in reducing the risk of mother-to-child transmission of HIV. It's a standard care practice for managing HIV-positive pregnant women.
Choice C rationale
Preparing for a caesarean section may be recommended to reduce the risk of vertical transmission of HIV during delivery, especially if the viral load is high.
Choice D rationale
Internal fetal scalp electrodes are contraindicated because they can create a portal for HIV transmission from mother to baby through small abrasions or punctures on the fetal scalp.
Correct Answer is A
Explanation
Choice A rationale
Administering antipyretics for maternal fever is essential as elevated maternal temperatures can increase the risk of fetal tachycardia and potentially lead to fetal distress. Reducing fever promptly is a priority to stabilize both maternal and fetal conditions.
Choice B rationale
Preparing for an emergency cesarean section is not the immediate step for maternal fever; instead, managing the fever and assessing the need for further interventions based on the overall clinical picture should be prioritized.
Choice C rationale
Administering glucocorticoids is indicated for promoting fetal lung maturity in preterm labor, not specifically for maternal fever management. Fever management requires antipyretics and hydration.
Choice D rationale
Waiting 4 hours to recheck temperature delays prompt management, increasing risks for both the mother and fetus. Immediate action to reduce fever is crucial to prevent potential complications.
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