A pregnant client in labor is having contractions about 4 minutes apart but rarely higher than 20 mm Hg in strength with resting tone ranging from 5 to 8 mm Hg. The client asks what can be done to make contractions more effective.
What is the nurse's best response to the client?
You may need oxytocin to strengthen contractions.
Relax, because contractions of this kind will strengthen by themselves.
Get some rest, because the contractions are hypertonic.
Try sitting up a little more erect to make the contractions more regular.
The Correct Answer is A
Choice A rationale
Contractions that are only 20 mm Hg in strength with a baseline resting tone of 5 to 8 mm Hg indicate hypotonic uterine dysfunction. This is characterized by insufficient uterine contraction power, not hypertonic resting tone. Oxytocin is an exogenous hormone that mimics the effects of the naturally released hormone, acting on uterine smooth muscle cells to increase the frequency, duration, and strength (intensity) of the contractions, which should ideally be 50 to 80 mm Hg during active labor.
Choice B rationale
Suggesting relaxation is inappropriate because these contraction patterns are ineffective and unlikely to spontaneously strengthen enough to cause adequate cervical change. Hypotonic contractions typically lead to a protracted labor pattern. The smooth muscle fibers of the uterus require sufficient stimulation to fully activate the contractile proteins actin and myosin. The low intensity and inadequate pressure of these contractions will not result in optimal cervical effacement and dilation.
Choice C rationale
These contractions are hypotonic, not hypertonic. Hypertonic contractions are characterized by high resting tone (above 15 mm Hg) and often painful, ineffective, erratic contractions. A period of rest is generally recommended for hypertonic contractions to reduce uterine irritability and oxygen consumption. However, for hypotonic dysfunction, augmentation (Choice A) is usually required to safely expedite the labor process and reduce risk of infection.
Choice D rationale
While upright positions like sitting or walking can use gravity to help the fetal head apply pressure to the cervix and stimulate endogenous oxytocin release, this response is less effective than recognizing the need for potential pharmacological augmentation. The contractions are described as rarely higher than 20 mm Hg, suggesting a significant need for intervention beyond simple position change to achieve the necessary 50 to 80 mm Hg intensity for progression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Following the evacuation of a hydatidiform mole, the client is at risk for developing gestational trophoblastic neoplasia (GTN). Pregnancy must be avoided for at least six to twelve months to ensure that any persistent or new human chorionic gonadotropin (hCG) elevation is due to GTN and not a new normal pregnancy. Three months is the minimum duration often discussed.
Choice B rationale
Follow-up care, including weekly hCG level monitoring until the level is undetectable, then monthly for six to twelve months, is crucial for early detection of malignant transformation (choriocarcinoma). Therefore, six weeks of follow-up care is insufficient for proper surveillance and risk management.
Choice C rationale
A history of a hydatidiform mole is indeed a risk factor for recurrence, with a recurrence rate of approximately 1–2%. However, the immediate priority for discharge teaching focuses on preventing the hCG confounding effect of a new pregnancy and ensuring compliance with the necessary hCG monitoring protocol.
Choice D rationale
Chemotherapy is indicated if the hCG levels plateau or increase, or if there is evidence of metastasis, rather than if they decrease. A decrease in hCG levels is the desired outcome after evacuation and indicates successful treatment without the need for chemotherapy.
Correct Answer is A
Explanation
Choice A rationale
Facial paralysis in a newborn after a forceps delivery is most often due to trauma to the facial nerve (cranial nerve VII), typically caused by pressure from the instrument against the nerve where it exits the stylomastoid foramen. This injury is usually a temporary neuropraxia (a physiological block with intact axons) which resolves spontaneously as the swelling subsides and compression is relieved, often within a few days to a few weeks, making close monitoring appropriate.
Choice B rationale
Phototherapy is the standard treatment for neonatal hyperbilirubinemia (jaundice), a condition where unconjugated bilirubin levels are elevated (normal total bilirubin is <5 mg/dL in the first 24 hours), which is a metabolic issue. Facial paralysis is a mechanical nerve injury related to birth trauma, and therefore, phototherapy has no therapeutic effect on nerve function or paralysis resolution.
Choice C rationale
While a neurologist consultation might be needed for persistent or severe paralysis that does not begin to show signs of improvement after several weeks, initial management involves expectant monitoring. The vast majority of these injuries are mild and transient, making immediate, routine referral unnecessary and potentially causing undue parental anxiety without an immediate need for specialized intervention.
Choice D rationale
There is typically no physiological contraindication to immediate or continued breastfeeding with this type of facial nerve injury. However, the nurse should assess the infant's ability to latch and suck effectively, as paralysis might compromise the motor function required for feeding, but is not a reason to universally prohibit all attempts at breastfeeding.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.