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
A family history of breast cancer, particularly in a close relative like a sister, is a significant risk factor for breast cancer.
Choice B rationale
Exposure to radiation, particularly in the chest area, increases the risk of developing breast cancer.
Choice C rationale
Current use of oral contraceptives can slightly increase the risk of breast cancer, though the risk diminishes after stopping the pills.
Choice D rationale
Age less than 25 years is not a risk factor for breast cancer; risk increases with age.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Recurrent variable decelerations can indicate umbilical cord compression. Notifying the provider ensures immediate intervention if necessary to address potential fetal distress and to monitor labor progression.
Choice B rationale
Ambulation is not recommended with recurrent variable decelerations. It might increase the risk of cord prolapse or other complications, further compromising fetal wellbeing.
Choice C rationale
Repositioning to the left lateral position helps improve uteroplacental blood flow and reduce cord compression, addressing the decelerations and promoting fetal oxygenation.
Choice D rationale
Performing a sterile vaginal exam can help identify any immediate issues like cord prolapse or rapid cervical changes that could impact labor management and fetal wellbeing.
Choice E rationale
Providing an IV fluid bolus can improve maternal hydration and placental perfusion, potentially alleviating the cause of variable decelerations by increasing blood flow and reducing cord compression effects. .
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