A nurse on a labor unit is admitting a client who is lying supine in her bed and reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min,
maternal heart rate 128/min, and maternal blood pressure 82/54 mm Hg. Which of the following is the first priority action for the nurse to take?
Reposition the client with one hip elevated or on her left side.
Notify the provider of the findings.
Ask the client if she needs pain medication.
Have the client empty her bladder.
The Correct Answer is A
A) Reposition the client with one hip elevated or on her left side: This is the correct first priority action. The client's vital signs indicate hypotension (low blood pressure), which may be caused by supine hypotensive syndrome. This condition occurs when the pregnant uterus compresses the vena cava, reducing blood return to the heart and causing a drop in blood pressure. Repositioning the client on her left side or elevating one hip can relieve the pressure on the vena cava and
improve blood flow to both the mother and the baby.
B) Notify the provider of the findings: While it is essential to inform the provider about the client's status, the first priority is to address the potential cause of hypotension and maternal discomfort.
C) Ask the client if she needs pain medication: Pain management is essential, but the client's vital signs and potential hypotensive condition take precedence as the first priority.
D) Have the client empty her bladder: Emptying the bladder can help reduce pressure on the vena cava and may improve blood flow, but it is not the first priority action in this situation. Repositioning the client is the initial priority to relieve supine hypotensive syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Engagement of the presenting part occurs when the baby's head descends into the pelvis. While it is a sign of labor progression, it can also happen weeks before labor begins.
Choice B: Progressive changes in the effacement (thinning) and dilation (opening) of the cervix are the most reliable signs of true labor. As the cervix changes, it indicates that labor is actively occurring.
Choice C: Rupture of the membranes (water breaking) is another sign of labor, but it can happen before or during labor. It may not be the most reliable sign by itself.
Choice D: Regular and frequent contractions are essential for labor to progress, but an irregular pattern of contractions may still be associated with false labor or early labor.
Correct Answer is A
Explanation
Choice A: Variable decelerations on the fetal heart rate monitor tracing are suggestive of umbilical cord compression. These decelerations are often V, U, or Wshaped, and their onset, depth, and duration can vary. They are associated with cord compression, which can reduce blood flow to the fetus during contractions. Other options are as follows:
Choice B: Late decelerations are indicative of uteroplacental insufficiency and are not related to umbilical cord problems.
Choice C: Accelerations are reassuring and suggest a responsive, healthy fetus.
Choice D: Early decelerations are usually benign and result from head compression during contractions, not umbilical cord issues.
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