A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130\/min. maternal heart rate 128\/min and maternal blood pressure 92\/54 mm Hg. Which of the following is the priority action for the nurse to take?
A.
Have the client void.<\/p>\n\n\n\n
B.
Position the client with one hip elevated.<\/p>\n\n\n\n
C.
Ask the client if she needs pain medication.<\/p>\n\n\n\n
D.
Notify the provider of the findings.<\/p>\n\n\n\n
The Correct answer and Explanation is:<\/mark><\/strong><\/p>\n\n\n\n The correct answer is B. Position the client with one hip elevated.<\/strong><\/p>\n\n\n\n In this scenario, the nurse is admitting a client in labor with painful contractions, a duration of 1 minute, and a frequency of every 3 minutes. The vital signs indicate a fetal heart rate of 130 beats per minute, which is within the normal range, but the maternal heart rate is elevated at 128 beats per minute, and maternal blood pressure is low at 92\/54 mm Hg. These findings suggest that the mother may be experiencing some degree of hypotension, possibly due to factors such as pain, anxiety, or a physiological response to labor.<\/p>\n\n\n\n Positioning the client with one hip elevated (usually the left hip) is an important intervention in this situation. This position helps to relieve pressure on the inferior vena cava, which can be compressed in the supine position, potentially improving maternal and fetal blood flow. Improved venous return to the heart can enhance perfusion, addressing the maternal hypotension and supporting fetal well-being.<\/p>\n\n\n\n While asking the client about pain medication (option C) is important for managing her discomfort, it does not address the immediate concern of maternal hypotension. Having the client void (option A) can be beneficial, but it does not directly impact the current cardiovascular status. Notifying the provider (option D) may also be necessary later on, especially if the maternal blood pressure does not improve, but the immediate priority is to stabilize the client’s condition through appropriate positioning.<\/p>\n\n\n\n In summary, positioning the client with one hip elevated is the most appropriate and immediate action to improve circulation and stabilize both maternal and fetal conditions during labor.<\/p>\n","protected":false},"excerpt":{"rendered":" A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130\/min. maternal heart rate 128\/min and maternal blood pressure 92\/54 mm Hg. Which […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-141904","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/141904","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=141904"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/141904\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=141904"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=141904"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=141904"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}