A nurse on a labor and delivery unit is assisting in the care of a client who is at 39 weeks of gestation and is in the first stage of labor.

Exhibits

Complete the diagram by dragging from the choices below to specify what complication the client is most likely experiencing, 2 actions the nurse should take to address that complication, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Complication:

Variable Fetal Heart Rate Decelerations: Variable decelerations are typically associated with cord compression, which may occur during labor, especially with oligohydramnios (low amniotic fluid). The fetal heart rate drops to 100 bpm with contractions but recovers within 30 seconds, fitting the description of variable decelerations. Since amniotic fluid cushions the umbilical cord, a reduction in fluid can increase the likelihood of cord compression.

Actions to Take:

Turn client to left side: Repositioning the client to the left lateral position can relieve pressure on the umbilical cord, improve blood flow to the placenta, and reduce the occurrence of variable decelerations.
Initiate amnioinfusion: An amnioinfusion is a procedure where a sterile fluid is introduced into the uterus to increase the amount of amniotic fluid, reducing cord compression and improving fetal oxygenation. This can help alleviate variable decelerations caused by oligohydramnios.

Parameters to Monitor:

Fetal Heart Rate Baseline: Monitoring the fetal heart rate baseline is essential to assess if the decelerations are improving after interventions, ensuring the fetus is not in distress and maintaining an appropriate heart rate (120–160 bpm).
Uterine Contraction Frequency: Monitoring the frequency of contractions is important, especially if an amnioinfusion is performed, to ensure contractions are not becoming too frequent or too intense, which could further compromise fetal oxygenation and lead to distress.

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Correct Answer is C

Explanation

A. Encouraging the client to rest between contractions: While resting between contractions is important, it is not directly related to the gate control theory of pain, which involves blocking pain signals.

B. Turning the client onto her left side. Positioning can help with circulation and comfort, but it does not directly reflect the gate control theory of pain.

C. Massaging the client's back. The gate control theory suggests that non-painful stimuli, such as massage, can "close the gate" to painful stimuli and help reduce the sensation of pain.

D. Administering prescribed analgesic medication: While medications help relieve pain, they are not based on the gate control theory, which focuses on physical interventions to block pain signals.

A. "This is a cephalhematoma, which will resolve on its own in 3 to 5 days." B. "This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor." C. "This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin." D. "This is a Mongolian spot, which is found on many newborns."

Correct Answer is B

Explanation

A. "This is a cephalhematoma, which will resolve on its own in 3 to 5 days." A cephalhematoma is a collection of blood between the skull bone and periosteum, and it does not cross suture lines. Caput succedaneum, on the other hand, does cross suture lines.

B. "This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor." Caput succedaneum is swelling of the soft tissues of the scalp caused by pressure during birth, especially with vacuum extraction, and it crosses suture lines.

C. "This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin." Erythema toxicum is a common newborn rash, but it does not cause swelling on the head or cross suture lines.

D. "This is a Mongolian spot, which is found on many newborns." Mongolian spots are bluish-gray marks usually found on the lower back or buttocks, not on the head, and they are not related to vacuum extraction or swelling.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

Correct Answer is C

Explanation

A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is assisting in the care of a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

A laboring patient reports to the nurse that "I think my water just broke!" The first action the nurse should take is:

The nurse is preparing to assist the nurse midwife with an amnioinfusion. The patient asks, "Why do I need this?" The best response by the nurse is:

A nurse is reinforcing teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the nurse include?

A nurse is assisting in the care of a client who is in the second stage of labor. Which of the following findings should the nurse report to the provider?

What is the primary purpose of assessing fetal heart rate patterns during labor and delivery?

Once your client's amniotic membranes have ruptured you need to evaluate the amniotic fluid for the following. (please select all that apply)

During the active phase of labor, which of the following is a common sign that indicates progress?