A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3 cm. The nurse's assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider prescribes an oxytocin drip.
Which data is most important for the nurse to monitor?

Client's hourly blood pressure.

Preparation for emergency cesarean birth.

Checking the perineum for bulging.

Intensity, interval, and length of contractions.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Monitoring hourly blood pressure is essential, but it is not the most crucial data in this scenario. Blood pressure monitoring can help identify maternal hypotension or hypertension, which can affect uteroplacental blood flow. However, hypotonic dystocia requires monitoring contractions to assess labor progression and effectiveness of oxytocin.

Choice B rationale

Preparing for an emergency cesarean birth is a potential intervention if labor does not progress or if fetal distress occurs. However, it is not the primary data to monitor initially. The decision for a cesarean is based on a comprehensive assessment, including fetal heart rate patterns and contraction quality.

Choice C rationale

Checking the perineum for bulging may indicate imminent delivery or fetal descent. However, in the context of hypotonic dystocia, the primary concern is evaluating contraction patterns to ensure the effectiveness of oxytocin in augmenting labor.

Choice D rationale

Monitoring the intensity, interval, and length of contractions is the most critical data in this case. Hypotonic dystocia involves weak, infrequent, or irregular contractions. Oxytocin is administered to strengthen and regularize contractions, so assessing their characteristics is crucial to determine the response to treatment and guide further interventions.

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Correct Answer is B

Explanation

Choice B rationale

Informing the anesthesia care provider is the priority action. Ingesting coffee within a few hours before surgery can affect anesthesia management, and the anesthesia team needs to be aware of any potential complications.

Choice A rationale

Starting the IV is important but not the priority in this scenario. The anesthesia care provider needs to be informed first.

Choice C rationale

Contacting the obstetrician is also important but comes after informing the anesthesia care provider.

Choice D rationale

Ensuring preoperative lab results are available is essential, but the first step should be to inform the anesthesia care provider about the coffee intake.

A. Bulb syringe use. B. Newborn screening tests. C. Techniques to breastfeed. D. Circumcision care.

Correct Answer is C

Explanation

Choice A rationale

While bulb syringe use is important for clearing the newborn's airways, it is not the immediate priority during the fourth stage of labor. This information can be provided later during routine newborn care education.

Choice B rationale

Newborn screening tests are important for identifying potential health issues, but the fourth stage of labor is focused on stabilizing the mother and infant and initiating breastfeeding. Screening information can be shared during the postpartum period.

Choice C rationale

Techniques to breastfeed are critical information to provide during the fourth stage of labor as it helps establish successful breastfeeding early on. This support can enhance maternal-infant bonding and promote breastfeeding success.

Choice D rationale

Circumcision care is relevant for parents who choose to circumcise their infant, but it is not the immediate priority during the fourth stage of labor. This information can be provided during subsequent postpartum visits.

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Naxlex Comprehensive Predictor Exams

At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache.Which action should the nurse take first?

Correct Answer is B

Explanation

A primigravida client is in the fourth stage of labor after the delivery of a newborn male infant.Which information should the nurse provide?

Correct Answer is C

Explanation

A client at 37 weeks gestation presents with contractions every 3 to 4 minutes, lasting 60 seconds.The fetal heart rate is noted to be 140 bpm, and no abnormal fetal movements are observed.The client reports no pain and normal laboratory results.Which action should the nurse implement first?

A client who is scheduled for induction of labor receives a prescription for oxytocin 2 milliunits/min intravenously (IV). The IV bag contains oxytocin 20 units in lactated Ringer's 1 liter. How many mL/hour should the nurse program the infusion pump to deliver? (Enter numerical value only)

The nurse is caring for a postpartum client who delivered 5 hours ago, and has saturated a perineal pad with clots within the last 15 minutes.Which action is most important for the nurse to implement?

A new mother asks the nurse why her infant son has a needle mark on his leg.Which response is best for the nurse to provide this mother?

A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn.Which medication should the nurse administer to the newborn?

In preparing a gravid client for a triple screen analysis, which action should the nurse take?

The nurse determines the need to perform further assessment based on the client's situation.Select the 2 actions that the nurse should perform immediately.

The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces (2.2 kg), has a head circumference of 13 inches (33 cm), and a chest circumference of 10 inches (25.4 cm). Based on these physical findings, assessment for which condition has the highest priority?