The nurse is managing care of a primigravida at full term who is in the active phase of labor.
What should be included in developing the plan of care for this client?
Supine positioning on back if it is comfortable.
Anesthesia/pain level assessment every 30 minutes.
Vaginal bleeding and fundus of the uterus after delivery of the placenta.
Oxygen saturation monitoring every half hour.
The Correct Answer is B
Choice A rationale
Supine positioning can compress the vena cava, leading to decreased venous return, reduced cardiac output, and potential maternal hypotension, which can compromise fetal oxygenation. Alternative positions like lateral or semi-recumbent are generally preferred during labor to optimize blood flow.
Choice B rationale
Assessing anesthesia or pain level every 30 minutes is crucial in the active phase of labor to evaluate the effectiveness of pain management interventions and the client's comfort. This frequent monitoring allows for timely adjustments to the pain management plan based on the client's subjective experience and physiological responses.
Choice C rationale
While assessing vaginal bleeding and the fundus is important in the postpartum period to monitor for uterine involution and hemorrhage, it is not the priority during the active phase of labor. The focus during active labor is on maternal and fetal well-being during the labor process itself.
Choice D rationale
Continuous or intermittent oxygen saturation monitoring may be indicated based on the client's condition and fetal heart rate patterns, but it is not a routine assessment every half hour for all clients in active labor. It is typically reserved for situations of suspected maternal hypoxemia or fetal distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Puerperal infection, an infection of the reproductive tract after childbirth, is a risk factor for all postpartum women. However, a large newborn size (macrosomia) increases the risk of prolonged labor, increased instrumentation during delivery, and postpartum hemorrhage, which indirectly increases the risk of infection but is not the most direct immediate risk related to the newborn's weight.
Choice B rationale
Retained placental fragments are a risk factor when the placenta does not deliver intact. While a large newborn can sometimes be associated with difficulties during placental delivery, it is not the primary direct risk factor immediately following birth. Uterine atony is a more immediate and direct risk related to uterine overdistension.
Choice C rationale
Thrombophlebitis, the formation of blood clots in the veins, is a postpartum risk factor related to hormonal changes, immobility, and hypercoagulability. While factors like prolonged labor (more common with large babies) can contribute, it is not the most immediate and direct risk in the first few hours postpartum for a woman who delivered a large newborn.
Choice D rationale
A newborn weighing 9 lb 6 oz (4252 g) is considered macrosomic. This large size can lead to overdistension of the uterus during pregnancy and labor. Uterine overdistension impairs the ability of the uterine muscles to contract effectively after delivery, a condition known as uterine atony. Uterine atony is the primary and most immediate risk for postpartum hemorrhage in women who have delivered large newborns. .
Correct Answer is A
Explanation
Choice A rationale
A reactive non-stress test indicates fetal well-being. The criteria for a reactive NST in a fetus greater than 32 weeks gestation include two or more fetal heart rate accelerations of at least 15 beats per minute above the baseline lasting for at least 15 seconds within a 20-minute period. The baseline fetal heart rate should be within the normal range of 110 to 160 beats per minute. This client's results meet these criteria.
Choice B rationale
A non-reactive non-stress test lacks the required number of fetal heart rate accelerations or the accelerations do not meet the amplitude or duration criteria within the specified time frame. This suggests the fetus may be experiencing some form of stress and requires further evaluation.
Choice C rationale
A negative non-stress test is not a standard term used to describe NST results. The test is categorized as either reactive (indicating fetal well-being) or non-reactive (suggesting potential fetal compromise).
Choice D rationale
A positive non-stress test is also not a standard term used for NST interpretation. A positive result in fetal monitoring typically refers to a contraction stress test where late decelerations are observed, indicating potential uteroplacental insufficiency.
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