A client in labor is receiving epidural anesthesia. What is the priority nursing intervention?

Correct Answer: C

Rationale: In the context of a client in labor receiving epidural anesthesia, the priority nursing intervention is to frequently check maternal blood pressure (Option C). This is crucial because epidural anesthesia can cause hypotension, which can lead to decreased placental perfusion and compromise fetal oxygenation. Monitoring blood pressure allows for early detection of hypotension, enabling prompt intervention to maintain maternal and fetal well-being. Assessing for bladder distention (Option B) is important to prevent urinary retention, but it is not the priority when compared to monitoring blood pressure in this specific scenario. Monitoring maternal heart rate (Option A) is important, but blood pressure takes precedence due to its direct impact on perfusion. Encouraging frequent position changes (Option D) can help with labor progress and comfort but is not as critical as monitoring blood pressure in this situation. Educationally, this question highlights the importance of understanding the potential complications associated with epidural anesthesia during labor and the significance of prioritizing nursing interventions based on the client's condition and the potential impact on both maternal and fetal well-being. Nurses should be vigilant in monitoring vital signs and responding promptly to changes to ensure optimal outcomes for both the mother and the baby.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B) Contractions lasting 120 seconds. This finding would prompt the nurse to stop the oxytocin infusion because prolonged contractions can lead to uterine hyperstimulation, which can compromise fetal oxygenation and result in fetal distress. It is crucial to maintain an appropriate balance between uterine contractions for labor progress and ensuring fetal well-being during labor induction. Option A) Contractions every 2-3 minutes can be a normal response to oxytocin induction, but it alone does not indicate a need to stop the infusion. Option C) Baseline fetal heart rate of 140 beats/minute is within the normal range for a fetus at term and does not require stopping the infusion. Option D) Client reports mild back pain is a common discomfort during labor and is not a reason to discontinue the oxytocin infusion. Educationally, understanding the potential risks and complications of oxytocin administration during labor induction is essential for nurses caring for laboring women. It is crucial for nurses to recognize abnormal findings and take prompt actions to ensure the safety and well-being of both the mother and the fetus. Continuous monitoring and assessment skills are vital in obstetric care to provide safe and effective care during the labor and delivery process.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Fetal heart rate of 180 beats/minute. This finding requires immediate action because it indicates fetal distress, which is a serious concern during labor. A fetal heart rate of 180 beats/minute suggests fetal tachycardia, which can be a sign of insufficient oxygenation and potential hypoxia in the fetus. This situation requires prompt intervention to prevent adverse outcomes for the baby. Option A) Contractions lasting 90 seconds is not an immediate concern as long as there are no signs of fetal distress or hyperstimulation. Prolonged contractions can occur in some cases without causing harm. Option B) Contractions every 2-3 minutes can indicate hyperstimulation, but it may not be as urgent as fetal distress. Adjusting the oxytocin infusion rate can help manage this issue. Option D) Client reports mild nausea is not a critical finding in this context. Nausea can be a common side effect of oxytocin but does not pose an immediate threat to the fetus. Educationally, understanding the implications of fetal heart rate patterns and recognizing signs of fetal distress are crucial skills for nurses caring for laboring women. It is essential to prioritize interventions based on the urgency of the situation to ensure the best possible outcomes for both mother and baby.

Correct Answer: C

Rationale: In this scenario, option C, "True labor contractions increase in intensity and frequency," is the correct answer. This statement indicates understanding because true labor contractions, which signify the onset of active labor, typically become stronger and more frequent over time, leading to cervical dilation and effacement. This progression is crucial for the advancement of labor and eventual delivery of the baby. Option A, "True labor contractions are irregular and stop with rest," is incorrect. True labor contractions are regular, increasing in intensity, duration, and frequency as labor progresses. They do not subside with rest; in fact, they often become more pronounced with activity. Option B, "False labor contractions cause cervical dilation," is incorrect. False labor contractions, also known as Braxton Hicks contractions, do not cause cervical changes or lead to the onset of active labor. They are irregular and do not follow a pattern of increasing intensity and frequency. Option D, "False labor contractions are felt in the back," is also incorrect. While back pain can be a component of both true and false labor contractions for some individuals, it is not a definitive characteristic to differentiate between the two types of contractions. In an educational context, understanding the characteristics of true labor contractions is essential for expectant parents to recognize the signs of labor onset and seek appropriate medical care. Educating prenatal class participants about the progression of labor helps them feel more prepared and confident as they approach childbirth.

Correct Answer: A

Rationale: In this scenario, the nurse's priority action should be to perform a nonstress test (Option A). This test is used to assess fetal well-being by monitoring the fetal heart rate in response to fetal movement. It helps determine if the fetus is receiving an adequate oxygen supply. Performing a nonstress test is crucial because decreased fetal movement could indicate fetal distress or compromise, which requires immediate attention to prevent adverse outcomes. This test provides real-time information on fetal status, guiding further interventions or decisions. Encouraging the client to drink orange juice (Option B) is not the priority action in this situation. While maternal hydration or consuming something sweet may sometimes encourage fetal movement, in cases of decreased fetal movement at 36 weeks, a more formal assessment like a nonstress test is needed to evaluate fetal well-being accurately. Scheduling an ultrasound (Option C) can provide detailed information about fetal status but may not be as immediate or readily available as a nonstress test in determining the current fetal response to stimuli. In cases of decreased fetal movement, time is critical, and the nonstress test offers a quicker assessment of fetal well-being. Notifying the healthcare provider (Option D) is important but should come after initiating the nonstress test. The provider should be informed of the situation and the test results, but the priority is to first assess the fetal well-being through the nonstress test. In the context of maternal newborn care, understanding the significance of fetal movement assessment and the appropriate interventions is vital for ensuring the health and safety of both the mother and the baby. Nurses need to prioritize prompt and accurate assessments to provide timely interventions and prevent potential complications during pregnancy.