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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

A reactive nonstress test demonstrates at least two accelerations in fetal heart rate, defined as an increase of 15 beats per minute above the baseline lasting for 15 seconds, within a 20-minute period. These accelerations indicate adequate fetal oxygenation and a healthy fetal autonomic nervous system response to movement.

Choice B rationale

Drawing blood to evaluate the baby's risk of genetic problems is typically performed through procedures like amniocentesis or chorionic villus sampling, not during a nonstress test. A nonstress test assesses fetal well-being based on heart rate patterns in response to fetal movement.

Choice C rationale

While fetal movement is an indicator of fetal well-being, the nonstress test specifically evaluates the fetal heart rate response to that movement. The number of movements within a specific time frame is a component of a biophysical profile, not the sole indicator in a nonstress test.

Choice D rationale

Ultrasound is used to visualize fetal anatomy and assess for congenital anomalies, which is a component of a fetal anatomy scan typically performed around 18-20 weeks of gestation. A nonstress test primarily monitors fetal heart rate and its reactivity.

A. Express small amounts of milk from the breasts to relieve the pressure. B. Wearing a loose-fitting bra to prevent nipple irritation. C. Apply cold packs to the breasts for comfort. D. Run warm water on her breasts during a shower.

Correct Answer is C

Explanation

Choice A rationale

Expressing milk when bottle-feeding can stimulate further milk production, which would exacerbate the engorgement and discomfort. The goal is to discourage milk production.

Choice B rationale

While a supportive bra is generally recommended for comfort, a loose-fitting bra might not provide adequate support to reduce swelling and discomfort associated with engorgement. A firm, supportive bra is usually advised.

Choice C rationale

Cold packs cause vasoconstriction, which helps to reduce blood flow to the breasts, thereby decreasing swelling, inflammation, and pain associated with engorgement. This provides symptomatic relief without stimulating milk production.

Choice D rationale

Warm water can stimulate milk flow, which is counterproductive when trying to suppress lactation in a bottle-feeding mother experiencing engorgement. Warmth increases blood flow and can worsen swelling and discomfort.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a nonstress test (NST) on a client who is at 36 weeks of gestation and asks "what are you looking for during this test?" Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A woman gave birth 48 hours ago to a healthy infant girl.She has decided to bottle feed.During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation.Which guidance should the nurse provide to the client at this time?

Correct Answer is C

Explanation

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When performing a Non-Stress test, the nurse interprets the finding of two accelerations of the fetal heart rate of 15 beats per minute above the baseline rate of 135 beats per minute lasting for 15 seconds in 20 minutes.This should be documented as:

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?