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 A
Explanation
Choice A rationale
G represents gravida, the total number of pregnancies, including the current one (2). T represents term births, the number of pregnancies delivered at 37 weeks gestation or later (1). P represents preterm births, the number of pregnancies delivered between 20 and 36 weeks gestation (0). A represents abortions, the number of pregnancies ending before 20 weeks gestation (0). L represents living children (1).
Choice B rationale
This option incorrectly states L as 2. The client has one living child from the previous pregnancy.
Choice C rationale
This option incorrectly states P as 1. The client's previous pregnancy was delivered at 38 weeks, which is considered a term birth, not preterm.
Choice D rationale
This option incorrectly states G as 3. The client is currently pregnant with twins, making this her second pregnancy in total.
Correct Answer is C
Explanation
Choice A rationale
Assessing vital signs is important in evaluating a postpartum hemorrhage, but it is not the immediate priority. Significant blood loss can occur before changes in vital signs become apparent due to compensatory mechanisms in the body. Addressing the source of bleeding is the initial critical step.
Choice B rationale
Calling the primary health care provider is a necessary step, but it should occur after the nurse has taken immediate action to address the likely cause of the excessive bleeding. Direct intervention to control the hemorrhage takes precedence over notification.
Choice C rationale
Massaging the fundus is the highest priority because uterine atony, a soft and boggy uterus that does not contract effectively, is the most common cause of early postpartum hemorrhage. Stimulating uterine contraction by massage can help to compress the blood vessels at the placental site and reduce bleeding.
Choice D rationale
Initiating an intravenous (IV) infusion of Ringer's lactate solution is important for volume replacement if bleeding is significant, but it is not the immediate first action. Addressing the uterine atony through fundal massage should be done first to try and control the bleeding.
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