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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.

Answer and Explanation

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.

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Correct Answer is []

Explanation

Condition: Preeclampsia with severe features.

2 actions:

Administer magnesium sulfate as prescribed,

Monitor for signs of magnesium toxicity.

2 parameters:

Urine output of at least 30 mL/hour,

Deep tendon reflexes.

Rationale for correct condition: Preeclampsia with severe features is indicated by the elevated blood pressure of 170/98 mm Hg and the need for magnesium sulfate. The goal is to prevent eclampsia and manage severe preeclampsia symptoms. The variable decelerations noted in the fetal heart rate are consistent with preeclampsia. The client's blood pressure is critically high, requiring immediate intervention. Magnesium sulfate is used to prevent seizures in severe preeclampsia.

Rationale for actions: Administering magnesium sulfate is essential to prevent seizures associated with severe preeclampsia. It stabilizes the client and reduces the risk of eclampsia. Monitoring for signs of magnesium toxicity ensures safe administration. Symptoms like respiratory depression and loss of reflexes indicate toxicity, requiring dose adjustment. Preparing for an emergency cesarean section is not immediately necessary. Placing the client in a supine position can worsen blood pressure. Restricting fluid intake is not a priority without signs of fluid overload.

Rationale for parameters: Monitoring urine output ensures kidney function and fluid balance. Preeclampsia can affect renal function, making this parameter critical. Deep tendon reflexes help assess neurological status and detect magnesium toxicity early. Changes in reflexes guide dosage adjustments. Fetal heart rate variability is important but secondary here. Oxygen saturation is stable and less relevant. Serum magnesium levels above 8 mg/dL indicate toxicity and are not the target.

Rationale for incorrect conditions: Gestational hypertension involves elevated blood pressure without severe features or the need for magnesium sulfate. Placental abruption would present with more severe pain and bleeding. Preterm labor does not align with the focus on hypertension and magnesium sulfate use.

A. Request placement of the epidural. B. Determine current cervical dilation. C. Decrease the oxytocin infusion rate. D. Give a bolus of intravenous fluids.

Correct Answer is B

Explanation

Choice A rationale

Requesting placement of the epidural should be based on the current cervical dilation and labor progress. Administering an epidural too early may lead to prolonged labor and increased risk of interventions.

Choice B rationale

Determining current cervical dilation is essential to assess the progress of labor and to make informed decisions about pain management and the use of epidurals. This ensures appropriate timing for interventions.

Choice C rationale

Decreasing the oxytocin infusion rate would not be the first action without assessing the current cervical dilation and labor progress. Oxytocin adjustments should be based on specific clinical indications and findings.

Choice D rationale

Giving a bolus of intravenous fluids is typically done before administering an epidural to prevent hypotension. However, this should be preceded by assessing cervical dilation to determine the timing and need for an epidural.

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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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control.Findings of the last vaginal exam, performed one hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station.Which action should the nurse implement first?

Correct Answer is B

Explanation

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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.