A nurse on a labor unit is admitting a client who 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 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
Have the client void.
Position the client with one hip elevated.
Ask the client if she needs pain medication.
Notify the provider of the findings.
The Correct Answer is B
The correct answer is B. Position the client with one hip elevated.
A. Having the client void is a good practice, but it is not the priority action in this situation. The client's vital signs suggest a potential issue with uteroplacental perfusion, and repositioning the client should be the priority.
B. Positioning the client with one hip elevated is the priority action.
The vital signs, specifically the low blood pressure, may be indicative of aortocaval compression (supine hypotension). Elevating one hip helps alleviate this compression, improving blood flow and potentially addressing the decreased blood pressure.
C. Asking the client if she needs pain medication is important, but repositioning the client takes precedence due to the potential issue with blood pressure and uteroplacental perfusion.
D. Notifying the provider is important, but repositioning the client to improve blood flow should be done first. The provider may be notified afterward based on the client's response and ongoing assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Cervical dilation.
A. Cervical dilation is a definitive sign of labor.
Cervical dilation is the opening of the cervix, and it is a key indicator of the active phase of labor. Measurement of cervical dilation is an essential component of assessing the progress of labor.
B. Brownish vaginal discharge may indicate various things, including the presence of old blood or mucus. While it could be a sign of impending labor, it is not a definitive confirmation of active labor.
C. Amniotic fluid in the vaginal vault could suggest rupture of membranes, but it alone does not confirm the active phase of labor.
D. Pain above the umbilicus is not a specific or conclusive sign of labor. Labor pain typically originates in the lower abdomen and pelvis.
Correct Answer is C
Explanation
The correct answer is C.
A. Calcium: While calcium is important for bone health, it is not specifically increased during early pregnancy. Adequate calcium intake is important throughout pregnancy, but the focus on increased intake typically occurs later in pregnancy to support fetal bone development.
B. Vitamin E: Vitamin E is important for overall health, but there is not a specific emphasis on increasing vitamin E intake in the early stages of pregnancy. It is generally included as part of a balanced diet.
C. Iron: This is the correct answer. Iron needs increase during pregnancy to support the increased blood volume and prevent iron-deficiency anemia. Adequate iron is crucial for the transport of oxygen to the developing fetus.
D. Vitamin D: While vitamin D is important for bone health and immune function, its increase is not specific to the early stages of pregnancy. Adequate vitamin D intake is essential throughout pregnancy, but it is not singled out as needing a significant increase at 8 weeks of gestation.
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