A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take?

No action is necessary since a decrease in the woman's blood pressure is expected.

Decrease her intravenous (IV) rate to a keep vein-open rate.

Encourage her to empty her bladder.

Turn the woman to the left lateral position or place a pillow under her hip.

Answer and Explanation

The Correct Answer is D

A. No action is necessary since a decrease in the woman's blood pressure is expected. While a drop in blood pressure is a common side effect of a spinal block, a 20% decrease is significant and can compromise placental perfusion, leading to fetal distress. Intervention is necessary to restore circulation.

B. Decrease her intravenous (IV) rate to a keep vein-open rate. This is incorrect because IV fluids help counteract hypotension. Instead of decreasing the IV rate, the nurse may need to increase fluid administration to improve blood pressure and maintain perfusion.

C. Encourage her to empty her bladder. A full bladder can affect labor progression but does not directly cause or correct hypotension. The priority in this scenario is restoring blood pressure to ensure adequate fetal oxygenation.

D. Turn the woman to the left lateral position or place a pillow under her hip. This is the most appropriate intervention. A left lateral position or elevating her right hip helps relieve aortocaval compression, improving blood flow to the uterus and stabilizing blood pressure. Additional interventions, such as IV fluid boluses or vasopressors (e.g., ephedrine), may be needed if hypotension persists.

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Correct Answer is B

Explanation

A. Induction of labor with intravenous oxytocin. Induction is contraindicated in cases of abruptio placentae with a Category III fetal heart rate tracing, as labor induction can worsen fetal distress and maternal bleeding. An immediate cesarean section is the safest intervention to prevent fetal and maternal complications.

B. An emergency cesarean section. A Category III fetal heart rate tracing with minimal variability and a prolonged deceleration indicates severe fetal distress, requiring immediate delivery. Partial abruptio placentae can cause fetal hypoxia, maternal hemorrhage, and potential fetal demise. The priority is an emergency cesarean section to ensure the best outcome for both mother and baby.

C. In-hospital fetal monitoring for 48 hours. Continuous monitoring is essential in cases of mild abruptio placentae without fetal distress, but in this case, a Category III tracing indicates an immediate threat to the fetus, making waiting inappropriate.

D. Discharge home on strict bed rest. Abruptio placentae is a serious obstetric emergency, and home management is never appropriate when fetal distress is present. Immediate intervention is necessary to prevent fetal and maternal complications.

A. Perform vaginal exam and apply upward digital pressure to the presenting part. B. Immediately turn the client to her side. C. Call the physician immediately. D. Place a moist, clean towel over the cord to prevent drying.

Correct Answer is A

Explanation

A. Perform vaginal exam and apply upward digital pressure to the presenting part. A prolapsed umbilical cord is an obstetric emergency that can lead to cord compression and fetal hypoxia. The priority intervention is for the nurse to manually lift the presenting part (usually the fetal head) off the cord to relieve pressure and restore blood flow. The nurse should maintain this position until an emergency cesarean section is performed.

B. Immediately turn the client to her side. Positioning changes, such as the knee-chest or Trendelenburg position, can help relieve pressure on the cord, but they are secondary to manually lifting the presenting part. While turning the client may assist, it is not the most immediate life-saving action.

C. Call the physician immediately. While notifying the provider is essential, relieving pressure on the umbilical cord takes priority. Delaying intervention to make a call could result in prolonged fetal hypoxia and compromise.

D. Place a moist, clean towel over the cord to prevent drying. Covering the cord with a moist towel helps prevent vasospasm and drying, but it does not relieve the compression that is cutting off oxygen to the fetus. The priority is to relieve pressure on the cord first before taking other measures.

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A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

The nurse discovers a loop of the umbilical cord protruding through the vagina when preparing to perform a vaginal examination. The priority intervention is to:

Correct Answer is A

Explanation

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