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 position refers to the relationship of a specific reference point on the fetus (usually the occiput, sacrum, or mentum) to the maternal pelvis, such as left occiput anterior (LOA). It describes how the fetus is oriented in relation to the maternal pelvis, not the relationship of fetal body parts to each other.
B. Fetal lie refers to the longitudinal axis of the fetus in relation to the maternal spine. It can be longitudinal, transverse, or oblique. While important in assessing labor, it does not describe the fetal body parts in relation to each other.
C. Fetal presentation refers to the part of the fetus that enters the maternal pelvis first, such as cephalic (head), breech (buttocks), or shoulder. Presentation does not describe the alignment of fetal body parts relative to each other.
D. Fetal attitude describes the relationship of the fetal body parts to one another, specifically the degree of flexion or extension of the fetal head, arms, and legs. The most common and favorable attitude for labor is general flexion, where the head is flexed, arms and legs are flexed, and the back is curved. This attitude allows the smallest diameter of the fetal head to pass through the birth canal, facilitating vaginal delivery.
Correct Answer is C
Explanation
A. Dry skin is a late sign of hypovolemic shock. Early shock often presents with normal skin turgor, and pallor or cool, clammy skin develops as the body compensates.
B. Being alert and oriented is expected in the early stages of hypovolemic shock because mental status changes occur later when perfusion to the brain is compromised.
C. Urinary output below 30 mL/hr is an early indication of hypovolemic shock. The kidneys are highly sensitive to decreased perfusion, and oliguria occurs as the body conserves fluid and maintains blood pressure, making this one of the first measurable signs of shock.
D. Hypotension is a late sign of hypovolemic shock. The body initially compensates with increased heart rate and vasoconstriction to maintain blood pressure, so a drop in blood pressure indicates advanced shock.
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