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: Bowel prep protocols are not required for an amniocentesis procedure, as it involves sampling amniotic fluid from the uterus, not the bowel.
Choice B: Emptying the bladder before the procedure is important to improve comfort and minimize the risk of accidental puncture during the amniocentesis.
Choice C: It is essential to have a full bladder for some ultrasound procedures, but it is not necessary for an amniocentesis. A full bladder can help push the uterus upward and make it easier to visualize the fetus during the ultrasound, but it is not relevant to the amniocentesis procedure.
Choice D: Washing the abdomen with soap and water is not a required step for an amniocentesis procedure. The procedure involves sterile preparation of the abdomen using an antiseptic
solution.
Correct Answer is C
Explanation
A. 1 cm below the umbilicus: This is too low for a client at 22 weeks of gestation.
B. 3 cm below the umbilicus: This is also too low for a client at 22 weeks of gestation.
C. 2 cm above the umbilicus: At 22 weeks of gestation, the fundus should be palpated about 2 cm above the umbilicus, which is at approximately the level of the maternal belly button.
D. 3 cm above the umbilicus: This is too high for a client at 22 weeks of gestation.
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