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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Vomiting: Vomiting is not a common complication of epidural anesthesia. Nausea can occur but is not directly related to the epidural block itself.
B) Tachycardia: Tachycardia is not a common complication of epidural anesthesia. It may occur due to other factors, but it is not directly associated with the epidural block.
C) Hypotension: Hypotension (low blood pressure) is a common complication of epidural anesthesia. The epidural can cause vasodilation, leading to a drop in blood pressure. It is essential to monitor the client's blood pressure and intervene promptly if hypotension occurs.
D) Respiratory depression: Respiratory depression is not a typical complication of epidural anesthesia. Epidural anesthesia mainly affects the lower part of the body and does not usually cause significant respiratory effects.
Correct Answer is ["B","E"]
Explanation
Choice A: Amniocentesis is not primarily performed to determine the gender of the fetus. The main indication for this procedure is to detect genetic abnormalities or chromosomal disorders.
Choice B: The primary purpose of an amniocentesis is to detect chromosomal abnormalities such as Down syndrome (trisomy 21), trisomy 18, and trisomy 13, among others.
Choice C: Rh incompatibility is assessed through blood tests, not amniocentesis. It involves determining the Rh factor of the mother's blood and monitoring for potential Rh sensitization.
Choice D: Cephalopelvic disproportion refers to a situation where the baby's head is too large or the mother's pelvis is too small to allow for a vaginal delivery. It is not related to amniocentesis.
Choice E: While detecting neural tube defects can be done through amniocentesis, it is not the primary indication for the procedure. Neural tube defects can also be screened for through blood tests and ultrasound examinations. Amniocentesis is more commonly used for chromosomal analysis.
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