At a prenatal visit at 36 weeks' gestation, a client complains of discomfort with irregularly occurring contractions (Braxton Hicks contractions). The nurse instructs the client to:

Walk around and increase fluid intake.

Time contractions for 30 minutes.

Take aspirin for the discomfort.

Go to the hospital.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Walking and increasing fluid intake can often alleviate the discomfort associated with Braxton Hicks contractions. Movement can sometimes cause the uterus to relax, and adequate hydration helps maintain uterine irritability within normal physiological limits. Dehydration can sometimes exacerbate uterine contractions, so ensuring sufficient fluid intake is a prudent measure.

Choice B rationale

Timing contractions is more relevant when assessing for true labor. Braxton Hicks contractions are irregular and do not follow a consistent pattern of increasing frequency, duration, and intensity. Instructing the client to time them for 30 minutes may cause unnecessary anxiety and is not the primary intervention for discomfort relief.

Choice C rationale

Aspirin is not recommended during pregnancy, especially in the third trimester, due to potential risks to both the mother and the fetus, such as increased bleeding tendencies. Furthermore, aspirin would not address the physiological cause of Braxton Hicks contractions.

Choice D rationale

Going to the hospital is not indicated for irregular, non-painful Braxton Hicks contractions, especially at 36 weeks' gestation. Hospital visits are reserved for signs of true labor, such as regular, increasing contractions, rupture of membranes, or significant bleeding.

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Correct Answer is C

Explanation

Choice A rationale

Encouraging a hands-and-knees position may help rotate a malpositioned fetus or relieve back pain, but it does not directly address hypotonic uterine dysfunction, which is characterized by weak, ineffective contractions. While it can improve maternal comfort and potentially aid in fetal descent if malpositioning is a contributing factor to slow labor progress, it will not augment the strength or frequency of contractions necessary for cervical dilation.

Choice B rationale

Providing a comfortable environment with dim lighting can promote relaxation and potentially enhance the progress of labor in cases of hypertonic uterine dysfunction (uncoordinated, painful contractions). However, in hypotonic dysfunction, the issue is a lack of adequate uterine muscle activity. While comfort measures are always important, they do not directly stimulate stronger contractions.

Choice C rationale

Administering oxytocin is the primary medical intervention for hypotonic uterine dysfunction. Oxytocin is a synthetic hormone that stimulates uterine smooth muscle to contract more frequently and with greater intensity. This augmentation of uterine activity aims to establish an effective labor pattern, leading to cervical dilation and fetal descent when fetopelvic disproportion has been ruled out.

Choice D rationale

Preparing for an amniotomy (artificial rupture of membranes) might be considered to augment labor if the membranes are intact. However, the question states the membranes have already ruptured. Amniotomy can sometimes stimulate contractions by releasing prostaglandins, but it is not the first-line intervention for established hypotonic dysfunction after membrane rupture, and oxytocin is generally more effective in this situation.

A. Encouraging the woman to assume a hands-and-knees position. B. Providing a comfortable environment with dim lighting. C. Administering oxytocin. D. Preparing the woman for an amniotomy.

Correct Answer is C

Explanation

Choice A rationale

Encouraging a hands-and-knees position can help rotate a fetus in an occiput posterior position or relieve back pain during labor. However, in hypotonic uterine dysfunction where contractions are weak and ineffective, this positional change alone is unlikely to augment labor significantly.

Choice B rationale

Providing a comfortable environment with dim lighting can reduce anxiety and promote relaxation, which might indirectly support labor progress. However, it does not directly address the issue of weak and ineffective uterine contractions characteristic of hypotonic dysfunction.

Choice C rationale

Administering oxytocin is the typical intervention for hypotonic uterine dysfunction after ruling out fetopelvic disproportion. Oxytocin is a synthetic hormone that stimulates uterine contractions, increasing their frequency, duration, and intensity to facilitate labor progress. It acts on the oxytocin receptors in the uterus, leading to smooth muscle contraction.

Choice D rationale

Preparing for an amniotomy (artificial rupture of membranes) might be considered to augment labor if the membranes are intact. However, since the woman's membranes have already ruptured, this intervention is not applicable in this situation. Amniotomy can sometimes stimulate or augment labor by releasing prostaglandins.

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At a prenatal visit at 36 weeks' gestation, a client complains of discomfort with irregularly occurring contractions (Braxton Hicks contractions). The nurse instructs the client to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses a client in labor and suspects dysfunctional labor (hypotonic uterine dysfunction). The woman's membranes have ruptured and fetopelvic disproportion is ruled out.Which intervention would the nurse expect to include in the plan of care for this client?

Correct Answer is C

Explanation

A nurse assesses a client in labor and suspects dysfunctional labor (hypotonic uterine dysfunction). The woman's membranes have ruptured and fetopelvic disproportion is ruled out.Which intervention would the nurse expect to include in the plan of care for this client?

Correct Answer is C

Explanation

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