A nurse is monitoring a client in labor whose contractions are 5 minutes apart. Which of the following is the most appropriate way to palpate uterine contractions to avoid further complications?
Place client in a knee chest position and palpate for fetal movement
Push down forcefully before each contraction
Avoid palpation entirely
Palpate gently between contractions to assess uterine tone
The Correct Answer is D
A. Placing the client in a knee-chest position is not necessary for routine assessment of contractions. This position may be used for specific interventions, such as relieving cord compression, but it does not aid in safe palpation of contractions.
B. Pushing down forcefully before each contraction is unsafe. Forceful palpation can increase discomfort, alter contraction patterns, or compromise fetal oxygenation, especially if uterine tone is high or the fetus is compromised.
C. Avoiding palpation entirely would limit the nurse’s ability to assess contraction frequency, duration, and intensity, which are essential parameters for evaluating labor progress and fetal well-being. Complete avoidance is not recommended unless contraindicated for specific reasons.
D. Palpating gently between contractions to assess uterine tone is the safest and most effective method. It allows the nurse to evaluate baseline uterine tone, contraction frequency, and strength without interfering with fetal oxygenation or increasing maternal discomfort. Gentle palpation helps detect hypertonicity or tetanic contractions, which can lead to fetal distress or uterine rupture if unrecognized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Fetal hypoxia is typically indicated by abnormal FHR patterns, such as late decelerations, decreased or absent variability, bradycardia, or prolonged decelerations. In this scenario, the FHR shows a normal baseline, moderate variability, and accelerations, all of which suggest adequate oxygenation and fetal well-being.
B. Tachycardia is defined as a baseline FHR greater than 160 beats per minute. Causes of fetal tachycardia can include maternal fever, infection, medications, or fetal hypoxia, but this fetus has a baseline of 135 bpm, which is within the normal range of 110–160 bpm, so tachycardia is not present.
C. Bradycardia is defined as a baseline FHR less than 110 beats per minute. Causes of bradycardia can include prolonged cord compression, maternal hypotension, or congenital heart conditions, but this fetus has a baseline of 135 bpm, ruling out bradycardia.
D. This fetus exhibits a reassuring FHR pattern characterized by a normal baseline indicating adequate cardiac function, moderate variability reflecting an intact autonomic nervous system and good oxygenation, presence of accelerations demonstrating a responsive, well-oxygenated fetus, and absence of decelerations, indicating there is no evidence of uteroplacental compromise or cord compression.
Correct Answer is D
Explanation
A. This is not the priority. While monitoring blood glucose is important in certain situations (e.g., diabetic clients), absent deep-tendon reflexes indicate magnesium sulfate toxicity, which requires immediate intervention to prevent serious complications, making glucose assessment secondary.
B. This is not indicated. Trendelenburg position does not address magnesium sulfate toxicity or prevent its complications, and it is not part of the standard response to absent reflexes.
C. This action is unrelated. The client is postpartum, so cesarean birth is not relevant. The priority is maternal safety and management of magnesium toxicity, not delivery.
D. This is correct and is the first action. Absent deep-tendon reflexes indicate magnesium sulfate toxicity, which can progress to respiratory depression, cardiac arrest, and neuromuscular paralysis if not addressed. The nurse should stop the infusion immediately, notify the provider, and prepare to administer calcium gluconate as the antidote if ordered. Additional supportive measures include monitoring respiratory rate, oxygen saturation, urine output, and cardiac status.
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