A nurse is assisting in the care of a client who is at 38 weeks of gestation.
What condition is the client most likely experiencing, what are 2 actions the nurse should take to address that
condition, and what are 2 parameters the nurse should monitor to assess the client’s progress?
The client is experiencing preterm labor.
The nurse should administer prescribed medication and encourage bed rest.
The nurse should monitor contraction frequency and fetal heart rate.
The Correct Answer is C
Choice C rationale:
Monitoring contraction frequency is essential to assess the progression of labor. Contractions are the tightening and relaxing of the uterine muscles that help to dilate the cervix and push the baby down the birth canal. The frequency of contractions is measured in minutes from the beginning of one contraction to the beginning of the next. As labor progresses, contractions become more frequent, regular, and intense. Monitoring contraction frequency helps the nurse to determine the stage of labor, assess the effectiveness of interventions, and identify any potential complications.
Monitoring fetal heart rate is crucial to assess the well-being of the baby during labor. The fetal heart rate is normally between 110 and 160 beats per minute. A normal fetal heart rate indicates that the baby is getting enough oxygen and is not in distress. Variations in the fetal heart rate, such as decelerations or tachycardia, can indicate potential problems and may require intervention.
Choice A rationale:
Preterm labor is defined as labor that begins before 37 weeks of gestation. The client in this scenario is at 38 weeks of gestation, which is considered term. Therefore, preterm labor is not the most likely condition.
Choice B rationale:
The administration of medication and bed rest may be appropriate interventions for preterm labor, but they are not the most appropriate interventions for a client in labor at 38 weeks of gestation. At this stage of pregnancy, labor is considered to be full-term, and interventions are focused on supporting the normal labor process and ensuring the safety of the mother and baby.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Retraction of the fetal head against the maternal perineum is a classic sign that the shoulders are about to be delivered. This is
known as the "turtle sign" because the fetal head appears to retract back into the body like a turtle's head.
It is important for the nurse to be prepared to assist with the delivery of the shoulders to ensure a safe and smooth delivery.
This includes:
Positioning the mother appropriately, such as in the McRoberts maneuver or a hands-and-knees position.
Applying gentle downward traction on the fetal head to help deliver the anterior shoulder.
Rotating the fetal shoulders as needed to facilitate delivery.
Monitoring the fetal heart rate closely for any signs of distress.
Choice B rationale:
While encouraging the mother to rest between contractions is important for conserving energy, it is not the priority action
when the fetal head is retracting. The nurse's focus should be on preparing for the delivery of the shoulders.
Choice C rationale:
Checking the mother's blood pressure is a routine part of labor and delivery care, but it is not specifically indicated when the
fetal head is retracting. There is no evidence to suggest that retraction of the fetal head is associated with changes in maternal
blood pressure.
Choice D rationale:
Administering oxygen to the mother may be helpful in some cases, such as if the fetal heart rate is showing signs of distress.
However, it is not the priority action when the fetal head is retracting. The focus should be on preparing for the delivery of the
shoulders.
Correct Answer is A
Explanation
The correct answer is Choice A
Choice A rationale: A distended bladder can displace the uterus upward and to the side, preventing proper uterine involution and increasing risk of postpartum hemorrhage.
Choice B rationale: Blood pressure of 130/84 mm Hg is within normal postpartum range and does not indicate urinary retention or bladder distention.
Choice C rationale: Moderate lochia rubra is expected postpartum and reflects normal uterine shedding, not urinary status.
Choice D rationale: Moderate labial swelling may occur from delivery trauma but does not directly indicate bladder fullness or urinary retention.
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