Health Promotion and Maintenance
69. A client, who is gravida 1, para 0, arrives in a labor and delivery unit at 38 weeks' gestation with mild irregular contractions. A sterile vaginal examination reveals the following: cervical dilation of 3 cm, 60% effaced, –1 station, and membranes intact. An external fetal monitor is placed and the fetal heart tracing reveals a baseline of 130 bpm, moderate variability, and accelerations to the 150s during contractions. Based on this information, which nursing action would be most appropriate?
Choices
. Turn the client to her left side and administer oxygen.
. Prepare the client for an immediate operative delivery.
. Begin an intravenous infusion for hydration.
. Send the client home and encourage her to ambulate.
Question Hint
Test-Taking Tip
The key to this question is the stage and phase of labor. Prodromal labor in a primipara can last several days. The fetal heart tracing is reassuring; therefore, the client can be safely discharged. Note that three of the options are active interventions (give O2, "immediate operative delivery," start IV). Choose the one that is a different option from the others ("send the client home").
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
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Health Promotion and Maintenance
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Answer 1 is incorrect because turning the client to her left side and administering oxygen is an intervention for fetal distress and there is no evidence of fetal distress. Answer 2 is incorrect because this is a reassuring fetal heart pattern; no immediate nursing actions other than comfort measures are necessary. Answer 3 is incorrect because the client is in no need for fluid volume expansion; neither she nor the fetus is in distress. Answer 4 is correct because this client is in prodromal labor. The fetal heart pattern is reassuring. There is no reason to admit the client to the hospital at this time. Ambulation at home may stimulate labor and descent of the presenting part, and decrease hospitalization time.
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