The nurse reviews the history and physical and nurses' notes to determine risk factors for this client.
Which potential issue(s) place the client at risk? Select all that apply.
Gravida 4: para 3.
Fetal heart rate 136 to 142 beats/minute.
Variable decelerations to 120 beats/minute lasting 20 seconds.
37-weeks, 1-day gestation by 10-week ultrasound.
Pain rating of 5 on 0 to 10 pain scale with each contraction.
Vaginal exam 4 cm dilated, 50% effaced, -3 station.
Contractions every 3 to 4 minutes, moderate to palpation.
A-blood type, received Rh(D) immune globulin.
Correct Answer : A,C,F
Choice A rationale
Gravida 4 para 3 indicates a history of multiple pregnancies and deliveries, which can increase the risk of uterine atony, postpartum hemorrhage, and placental issues. This client’s obstetric history makes her high-risk due to potential complications associated with multiparity.
Choice B rationale
A fetal heart rate of 136 to 142 beats/minute is within the normal range for a fetus, indicating good fetal well-being. This data point does not place the client at increased risk.
Choice C rationale
Variable decelerations to 120 beats/minute lasting 20 seconds suggest umbilical cord compression, which can lead to fetal hypoxia if persistent and untreated. Variable decelerations are an indicator of potential fetal distress, making this a significant risk factor.
Choice D rationale
A gestation of 37-weeks, 1-day is considered term, and while there may be some risks associated with early-term delivery, this data point alone does not significantly increase risk in a low-risk pregnancy.
Choice E rationale
A pain rating of 5 on a 0 to 10 pain scale with each contraction is indicative of moderate pain, which is expected during labor. Pain severity alone does not increase the client's risk for complications.
Choice F rationale
A vaginal exam showing 4 cm dilation, 50% effacement, and -3 station indicates early labor. However, the -3 station suggests that the fetus is still high in the pelvis, which can be a concern if there is prolonged labor or failure to progress.
Choice G rationale
Contractions every 3 to 4 minutes, moderate to palpation, are consistent with active labor and are not indicative of an increased risk for complications in this context.
Choice H rationale
An A-blood type and receiving Rh(D) immune globulin address Rh incompatibility and prevention of hemolytic disease in the newborn. This data point does not place the client at increased risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
- Blood pressure: 170/98 mm Hg: Abnormal. A blood pressure reading of 170/98 mm Hg is high, especially in the context of pregnancy, where it may indicate gestational hypertension or the potential for preeclampsia. This needs to be monitored closely.
- Pain rating: 5/10 with contractions: Normal. A pain rating of 5/10 is typical during labor, especially at this stage of dilation (4 cm). Pain management can be adjusted based on the client's preference and progress.
- Variable decelerations: 20 seconds: Normal. Occasional variable decelerations (drops in fetal heart rate that last for less than 30 seconds) can occur during labor, often due to umbilical cord compression. As long as the decelerations are brief and not repetitive or severe, they are typically not concerning.
- Magnesium sulfate infusion ongoing: Normal. The magnesium sulfate infusion is prescribed to manage potential complications, likely to prevent preterm labor or to prevent seizures in the event of preeclampsia. Its ongoing use is appropriate for this client at this stage.
Correct Answer is A
Explanation
Choice A rationale
Being 37-weeks, 1-day gestation is considered term. This timing indicates the fetus is likely mature and ready for birth, which reduces the risk of complications compared to preterm delivery. However, early-term delivery can still have some associated risks, such as respiratory issues or feeding difficulties.
Choice B rationale
A pain rating of 5 during contractions is within the expected range during active labor. Pain management is an important aspect of labor care, but it does not inherently increase or decrease the risk of complications.
Choice C rationale
The vaginal exam findings of 4 cm dilation, 50% effacement, and -3 station indicate early labor progression. However, the negative station suggests the fetus is still high in the pelvis, which could pose a risk if labor stalls or if there is cephalopelvic disproportion.
Choice D rationale
Contractions every 3 to 4 minutes are consistent with active labor. Regular and moderate contractions are expected and necessary for labor to progress. This data point alone does not increase the risk for complications.
Choice E rationale
An A- blood type with Rh(D) immune globulin received at 28 weeks is managed appropriately to prevent Rh sensitization. Rh(D) immune globulin reduces the risk of hemolytic disease of the fetus and newborn in subsequent pregnancies, making it an important preventative measure but not a current risk factor. .
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