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 C
Explanation
Choice A rationale
A pulse of 88 bpm is within the normal range for an adult and does not indicate any immediate concern that needs to be reported to the anesthesia provider.
Choice B rationale
A pain level of 1 on a 0 to 10 scale indicates that the epidural is effectively managing the client’s pain. This is a positive outcome and does not require reporting.
Choice C rationale
Blood pressure of 88/52 mmHg indicates hypotension, which is a common and potentially serious side effect of epidural anesthesia. Hypotension can lead to decreased placental perfusion and fetal distress, so it requires immediate attention and reporting to the anesthesia provider.
Choice D rationale
Dizziness can be a side effect of epidural anesthesia, but it is not as critical as hypotension. It should be monitored, but it does not require immediate reporting unless it is severe or accompanied by other symptoms.
Correct Answer is A
Explanation
Choice A rationale
- Thenon-stress test (NST)is reactive, indicating normal fetal heart rate patterns with adequate accelerations.
- Theultrasoundshows normal amniotic fluid index and fetal movements, with no abnormalities detected.
- The client has no significant medical history and is generally feeling well.
These findings suggest that the fetus is currently well, and there is no immediate need for further intervention. However, the client should be instructed to monitor fetal movements at home and return if there are any concerns or if decreased fetal movement persists. This approach balances the need for vigilance with the reassurance provided by the normal test results.
.
Choice B rationale
Continuous fetal monitoring is typically reserved for cases where there is a significant concern for fetal distress or other complications. In this case, both the non-stress test (NST) and ultrasound results are normal, indicating that the fetus is currently well. Therefore, continuous monitoring in a hospital setting is not necessary.
Choice C rationale
An immediate cesarean section is a major surgical procedure that is usually performed when there is an urgent risk to the mother or baby. Given the normal NST and ultrasound findings, there is no indication of fetal distress or other complications that would warrant such an intervention at this time.
Choice D rationale
Corticosteroids are given to enhance fetal lung maturity in cases where preterm delivery is anticipated, typically before 34 weeks of gestation. Since the client is already at 35 weeks and there is no indication of imminent preterm labor or other complications, administering corticosteroids is not necessary..