A nurse is caring for a term pregnant client in the labor and delivery unit who has arrived with complaints of very strong contractions that started one hour ago. The client reports feeling a lot of pressure in their bottom.
Complete the diagram below by dragging from the choices provided to specify:
- What condition the client is most likely experiencing
- Two actions the nurse should take to address that condition
- Two parameters the nurse should monitor to assess the client's progress
The Correct Answer is []
The condition of imminent delivery is correct because the client, gravida 5 para 4 at 39 weeks gestation, is experiencing strong contractions and rectal pressure indicative of advanced labor stages. The physical examination supports active labor, with a firm, palpable uterus, and fetal heart rate present. The urgency of notifying the healthcare provider and encouraging bearing down aligns with labor management in advanced stages. Cervical dilation is essential to assess labor progression, and fetal heart rate monitoring ensures fetal well-being during delivery.
Actions and Parameters Rationale:
- Notifying the healthcare provider immediately ensures timely medical intervention, crucial for safe delivery and management of any complications.
- Encouraging the client to bear down with contractions aids the birthing process by utilizing the client’s natural efforts in the expulsion phase of labor.
- Monitoring cervical dilation provides insight into how far along the client is in labor, helping to anticipate the time of delivery.
- Continuous monitoring of fetal heart rate ensures the baby's well-being, detecting any distress during labor.
Incorrect Conditions:
- Preterm labor (A): The client is at 39 weeks gestation, so the labor is not preterm.
- Placental abruption (B): There are no signs of placental abruption, such as vaginal bleeding, uterine tenderness, or abnormal fetal heart rate patterns.
- Prolapsed umbilical cord (C): There is no indication of a prolapsed cord, such as sudden fetal distress or visible/palpable cord.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Amniotic membrane bands can lead to congenital anomalies but are not directly associated with vasa previa.
Choice B rationale
The amount of amniotic fluid can affect pregnancy outcomes, but it is not a contributing factor to vasa previa.
Choice C rationale
Vasa previa is a rare obstetric complication that occurs when fetal blood vessels cross or run near the internal os of the uterus. This condition usually results from an abnormal insertion of the umbilical cord.
Choice D rationale
Placenta accreta refers to the abnormal adherence of the placenta to the uterine wall, which is a separate condition and not related to vasa previa.
Correct Answer is C
Explanation
Choice A rationale
Encouraging the patient to push harder during shoulder dystocia can worsen the situation by further impacting the shoulder against the pelvic bone.
Choice B rationale
Preparing for a cesarean birth is not the immediate priority action in the case of shoulder dystocia. Initial maneuvers should be attempted first.
Choice C rationale
Performing the McRoberts maneuver is the priority action. It involves hyperflexing the mother's legs tightly to her abdomen, which can help free the impacted shoulder.
Choice D rationale
Applying firm fundal pressure can worsen shoulder dystocia and should be avoided. Instead, suprapubic pressure can be applied to help dislodge the shoulder. .
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