A nurse is caring for a client at term in labor.
The client states, “I can’t do this anymore.”. She reports rectal pressure and increasing nausea. SVE (sterile vaginal exam) performed: 9 cm, 100% effaced, +1 station.
Encourage the client to continue pushing.
Prepare the client for delivery.
Administer pain relief as prescribed.
Reassure the client and provide emotional support.
The Correct Answer is B
Choice A rationale
Encouraging the client to continue pushing is not appropriate at this stage. The client is 9 cm dilated, which indicates that she is in the transition phase of labor, not yet fully dilated and ready to push. Pushing at this stage could cause cervical swelling and delay progress.
Choice B rationale
Preparing the client for delivery is the most appropriate action. The client is in the transition phase of labor, with 9 cm dilation, 100% effacement, and +1 station. This indicates that delivery is imminent, and the nurse should prepare for the birth process.
Choice C rationale
Administering pain relief as prescribed may be considered, but it is not the priority action at this stage. The client is in the transition phase, and administering pain relief could interfere with the natural progression of labor. Non-pharmacological support may be more appropriate.
Choice D rationale
Reassuring the client and providing emotional support is important, but it is not the primary action at this stage. The nurse should focus on preparing for delivery while also providing support and reassurance.
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View Related questions
Correct Answer is B
Explanation
Choice A rationale
Encouraging the client to walk around for 30 minutes and then resume monitoring is not the most appropriate action in this scenario. Walking may help stimulate fetal movement, but it is not the first-line intervention when there are no accelerations or fetal movement during a nonstress test. The nurse should try other methods to stimulate fetal movement before resorting to walking.
Choice B rationale
Performing vibroacoustic stimulation is the correct action. Vibroacoustic stimulation involves using a device to produce a sound and vibration near the maternal abdomen to stimulate fetal movement and heart rate accelerations. This method is non-invasive and can help determine fetal well-being by eliciting a response from the fetus.
Choice C rationale
Immediately reporting the situation to the provider and preparing the client for induction of labor is premature. The absence of accelerations or fetal movement during a nonstress test does not immediately indicate a need for induction of labor. Other less invasive interventions, such as vibroacoustic stimulation, should be attempted first.
Choice D rationale
Repositioning the client into a supine position is not recommended. The supine position can lead to supine hypotensive syndrome, which can decrease blood flow to the fetus. The nurse should avoid placing the client in a supine position and instead try other methods to stimulate fetal movement.
Correct Answer is C
Explanation
Choice A rationale
While a negative result in a Contraction Stress Test (CST) is desirable, this choice does not fully explain the significance of the result. A negative CST indicates that there are no late decelerations in the fetal heart rate in response to uterine contractions, suggesting that the fetus can handle the stress of labor.
Choice B rationale
This choice describes the criteria for a reactive Nonstress Test (NST), not a Contraction Stress Test (CST). In a CST, the focus is on the fetal heart rate response to contractions, not the number of contractions or variability.
Choice C rationale
A negative result in a CST indicates fetal well-being, meaning that the fetus can tolerate the stress of uterine contractions without showing signs of distress, such as late decelerations in the heart rate. This result suggests that the fetus is likely to handle labor well.
Choice D rationale
A positive result in a CST indicates that the fetus has late decelerations in response to contractions, which can be a sign of fetal distress. This result may suggest fetal growth restriction, lower Apgar scores, and the potential need for cesarean delivery. However, this choice does not fully capture the significance of a positive CST result.