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 C

Explanation

Choice A rationale

A respiratory rate of 50 breaths per minute is within the normal range for a newborn and does not indicate respiratory distress. Newborns typically have a higher respiratory rate than adults, and this is considered normal.

Choice B rationale

Shallow and irregular respirations can occur in healthy newborns and do not necessarily indicate respiratory distress. It is important to monitor for additional signs of distress before making a definitive assessment.

Choice C rationale

Flaring of the nares is a sign of respiratory distress in newborns as it indicates increased effort to breathe. This symptom is associated with conditions such as respiratory distress syndrome and requires prompt medical evaluation and intervention.

Choice D rationale

Abdominal breathing with synchronous chest movement is normal for newborns as their diaphragm is the primary muscle for respiration. This type of breathing pattern does not indicate respiratory distress and is expected in healthy newborns.

A. Explain that heartburn is a common discomfort. B. Ask if blurred vision and headache have occurred. C. Check urine for presence of glucose and ketones. D. Instruct the client to take an antacid as needed.

Correct Answer is B

Explanation

Choice A rationale

While heartburn is common during pregnancy due to hormonal changes and pressure from the growing uterus, the presence of 3+ bilateral pitting pedal edema raises concerns. This symptom could indicate a more serious condition, such as preeclampsia, and should not be dismissed as a normal discomfort.

Choice B rationale

Asking if blurred vision and headache have occurred is essential because these symptoms, along with significant edema, are indicators of preeclampsia. Preeclampsia is a serious pregnancy complication characterized by high blood pressure and damage to other organ systems, often requiring immediate medical attention.

Choice C rationale

Checking urine for glucose and ketones is relevant for assessing gestational diabetes but does not address the immediate concern of preeclampsia. The symptoms of edema and possible preeclampsia should be prioritized over concerns of gestational diabetes.

Choice D rationale

Instructing the client to take an antacid for heartburn does not address the critical issue of significant edema. While heartburn relief is important, the symptoms of edema need immediate evaluation to rule out preeclampsia or other complications.

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Naxlex Comprehensive Predictor Exams

The nurse is performing a newborn assessment.Which symptom, if present in a newborn, would indicate respiratory distress?

Correct Answer is C

Explanation

During a prenatal visit, a client at 30 weeks gestation reports persistent heartburn during the past two weeks.The nurse notes the client has 3+ bilateral, pitting, pedal edema.Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse is caring for a term infant immediately following delivery.Which action should the nurse implement to reduce the risk of cold stress?

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