The Labor and delivery triage nurse is assessing a primigravida at 38 weeks and 3 days gestation who reports uterine contractions that started 2 hours ago. Further examination reveals a cervix that is dilated at 1 cm and 20% effaced with intact membranes. What action will the nurse implement?
Inform the patient that they are in latent Labor.
Initiate Labor augmentation.
Prepare the patient for a caesarean delivery.
Anticipate admission to the Labor and delivery unit.
The Correct Answer is A
Choice A reason: Informing the patient that they are in latent Labor is appropriate in this situation. Latent Labor, also known as early Labor, is characterized by cervical dilation of up to 3 cm and mild contractions that may last for several hours or even days. It is important to educate the patient about the early stages of Labor and what to expect as it progresses.
Choice B reason: Initiating Labor augmentation is not necessary at this point. Labor augmentation is typically used when Labor is not progressing adequately. In this case, the patient is in the early stages of Labor, and there is no indication that augmentation is needed.
Choice C reason: Preparing the patient for a caesarean delivery is not warranted based on the information provided. The patient's condition does not suggest any immediate need for a caesarean section, and the Labor is still in its early stages.
Choice D reason: Anticipating admission to the Labor and delivery unit may not be required at this stage. Since the patient is in latent Labor, they may be advised to stay at home until Labor progresses further and the contractions become more intense and frequent. This helps reduce unnecessary hospital admissions and allows the patient to be more comfortable in their home environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Salmeterol, a long-acting beta-agonist (LABA), is generally not recommended for use during pregnancy due to potential risks to the fetes. It is typically avoided unless absolutely necessary and other safer options are not effective.
Choice B reason: Prednisone is a corticosteroid that can be used during pregnancy when necessary. It is often prescribed for managing severe asthma symptoms, but it should be used under close medical supervision to minimize potential risks.
Choice C reason: Ibuterol is a short-acting beta-agonist (SABA) and is generally considered safe for use during pregnancy. It is commonly used as a rescue inhaler to relieve acute asthma symptoms.
Choice D reason: The text for option D is incomplete and does not provide sufficient information to determine its relevance to the question.
Correct Answer is A
Explanation
Choice A reason: Informing the patient that they are in latent Labor is appropriate in this situation. Latent Labor, also known as early Labor, is characterized by cervical dilation of up to 3 cm and mild contractions that may last for several hours or even days. It is important to educate the patient about the early stages of Labor and what to expect as it progresses.
Choice B reason: Initiating Labor augmentation is not necessary at this point. Labor augmentation is typically used when Labor is not progressing adequately. In this case, the patient is in the early stages of Labor, and there is no indication that augmentation is needed.
Choice C reason: Preparing the patient for a caesarean delivery is not warranted based on the information provided. The patient's condition does not suggest any immediate need for a caesarean section, and the Labor is still in its early stages.
Choice D reason: Anticipating admission to the Labor and delivery unit may not be required at this stage. Since the patient is in latent Labor, they may be advised to stay at home until Labor progresses further and the contractions become more intense and frequent. This helps reduce unnecessary hospital admissions and allows the patient to be more comfortable in their home environment.
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