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 D

Explanation

Choice A rationale

Preparing to administer a prescribed oxytocic preparation is a possible intervention for postpartum hemorrhage, but the immediate first step should be to assess the uterus, the most common source of early postpartum bleeding.

Choice B rationale

Assessing the client's blood pressure is important in evaluating the extent of blood loss, but it is not the initial action to take. Addressing the likely cause of the bleeding should precede further assessment of vital signs.

Choice C rationale

Assessing the bladder for distention is important as a full bladder can displace the uterus and interfere with its contraction, potentially contributing to bleeding. However, directly addressing the uterine tone is the immediate first step.

Choice D rationale

Massaging the client's fundus is the priority action because uterine atony, a soft and non-contracted uterus, is the most frequent cause of early postpartum hemorrhage. Stimulating the uterus to contract by massage helps to compress the blood vessels at the placental site and decrease bleeding. .

A. Puerperal infection. B. Retained placental fragments. C. Thrombophlebitis. D. Uterine atony.

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. .

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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

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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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?