The nurse is caring for a multigravida client in active labor with continuous epidural anesthesia. When the client is 7 cm dilated, her blood pressure drops to 90/50 mm Hg, and the fetal heart rate shows signs of decelerations. What action should the nurse take first?

Correct Answer: A

Rationale: In this scenario, the most appropriate action for the nurse to take first is option A, which is to place the client in a lateral position. This intervention is crucial as it helps alleviate aortocaval compression, a condition that can occur during pregnancy when the weight of the uterus compresses the vena cava when the client is in a supine position. Aortocaval compression can lead to decreased blood return to the heart, resulting in decreased cardiac output and subsequent hypotension. By placing the client in a lateral position, the pressure on the vena cava is relieved, allowing for improved blood flow and potentially resolving the hypotension and fetal distress. Option B, administering oxygen via face mask, is not the priority in this situation as the primary issue is likely related to hypotension caused by aortocaval compression rather than oxygenation. While oxygen may be necessary if the fetal distress persists, it is not the most immediate concern. Increasing the rate of IV fluid infusion (option C) may exacerbate the hypotension by increasing fluid volume without addressing the underlying cause. It is important to address the positioning first to ensure optimal blood flow before considering fluid administration. Notifying the healthcare provider (option D) is important, but it is not the first action to take in this situation. The nurse must first intervene to address the hypotension and fetal distress promptly before informing the healthcare provider of the situation. Educationally, this scenario highlights the importance of understanding the physiological changes that occur during pregnancy and labor, as well as the significance of prompt nursing interventions in addressing emergent situations to promote the well-being of both the mother and the fetus.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take next is to monitor the fetal heart rate pattern (Option A). This is crucial because the client's membranes have ruptured, indicating that the client is at risk for infection due to the loss of the amniotic fluid's protective barrier. Monitoring the fetal heart rate helps assess the well-being of the fetus and can indicate any signs of distress or compromise, enabling timely interventions. Performing a vaginal examination (Option B) at this point can increase the risk of introducing infection, given that the membranes have already ruptured. Encouraging the client to ambulate (Option C) may not be suitable due to the need for close monitoring after membrane rupture. Administering pain medication (Option D) is not the priority at this moment, as fetal assessment takes precedence to ensure the well-being of both the mother and the baby. From an educational perspective, it is vital for nurses to understand the sequence of actions to take in managing a client in labor, especially when complications arise. This case emphasizes the importance of prioritizing fetal well-being and infection prevention strategies in maternal and reproductive health care settings.

Correct Answer: B

Rationale: In this scenario, the nurse should suspect preeclampsia as the correct condition. Preeclampsia is characterized by high blood pressure (hypertension), protein in the urine, and often involves symptoms like severe headache, visual disturbances, and epigastric pain. The presence of hypertension (150/100 mm Hg) along with the client's symptoms is indicative of preeclampsia, a serious condition that can lead to complications for both the mother and the baby if not managed promptly. Gestational hypertension (Option A) is high blood pressure that develops after 20 weeks of pregnancy but without the presence of protein in the urine or other signs of preeclampsia. Eclampsia (Option C) is a severe complication of preeclampsia characterized by seizures. Chronic hypertension (Option D) is high blood pressure that was present before pregnancy or diagnosed before 20 weeks of pregnancy. Educationally, understanding the differences between these conditions is crucial for nurses caring for maternal and reproductive health clients. Recognizing the signs and symptoms of preeclampsia, such as elevated blood pressure and associated symptoms, allows for timely intervention and management to prevent serious complications for both the mother and the baby. Early identification and appropriate management are key in providing safe and effective care to pregnant individuals.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take next is to monitor the fetal heart rate pattern. This is crucial as the client is in active labor, and monitoring the fetal heart rate helps assess the well-being of the fetus during this critical stage. Performing a vaginal examination (Option B) may increase the risk of infection since the membranes have already ruptured. Encouraging the client to ambulate (Option C) may not be suitable at this point due to the stage of labor and the need for continuous monitoring. Administering pain medication (Option D) could be considered based on the client's pain level, but ensuring fetal well-being through continuous fetal heart rate monitoring takes precedence in this situation. From an educational standpoint, understanding the significance of fetal heart rate monitoring in labor is crucial for ensuring optimal maternal and fetal outcomes. It allows for early identification of any potential issues, enabling prompt intervention if needed. Students and healthcare providers must prioritize fetal assessment during labor to provide safe and effective care for maternal and reproductive health clients.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take is to encourage the client to pant-blow during contractions (Option A). Pant-blowing during the second stage of labor helps prevent rapid pushing, which can lead to complications such as maternal exhaustion, perineal trauma, and fetal distress. By encouraging the client to pant-blow, the nurse can help the client control the urge to push and prevent pushing before the cervix is fully dilated. Assisting the client to push with contractions (Option B) is incorrect in this situation because the client's cervix is only dilated 8 cm, and pushing prematurely can cause cervical swelling and delay the progress of labor. Preparing for an immediate delivery (Option C) is also incorrect as the client is not fully dilated yet. Notifying the healthcare provider (Option D) is premature at this stage as well. From an educational standpoint, it is crucial for nurses to understand the importance of proper pushing techniques during labor to promote optimal maternal and fetal outcomes. By differentiating between appropriate and premature pushing, nurses can help ensure a safe and efficient labor process for both the client and the baby.