A gravida 1, para 0, 38 weeks' gestation is in the transition ...

[c0205847]

A gravida 1, para 0, 38 weeks' gestation is in the transition phase of labor with SROM and is very anxious. Vaginal exam, 8 cm, 100 effaced, -1 station vertex presentation.
 
  She wants the nurse to keep checking her by performing repeated vaginal exams because she is sure that she is progressing rapidly. What is the best response that the nurse can provide to this client at this time?
 
  a. Performing more frequent vaginal exams will not make the labor go any quicker.
  b. Even though she is in transition, frequent vaginal exams must be limited because of the potential for infection.
  c. Tell the client that she will check every 30 minutes.
  d. Medicate the client as needed for anxiety so that the labor can progress.

Question 2

If a woman's fundus is soft 30 minutes after birth, the nurse's first response should be to:
 
  a. massage the fundus.
  b. take the blood pressure.
  c. notify the physician or nurse-midwife.
  d. place the woman in Trendelenburg position.

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Answer to Question 1

ANS: B
Data reveals a primipara in labor who is in transition (8 to 10 cm) with ruptured membranes. At this point, vaginal exams should be limited until the client feels further pressure and/or has increased bloody show, indicating fetal descent. Telling the client that performing more frequent vaginal exams will not make the labor go any quicker would not be therapeutic because this does not address client's anxiety. Telling the client that the nurse will continue checking every 30 minutes without adequate clinical indication is not the standard of care. Medicating the client is not an appropriate intervention at this time because effective communication will help alleviate stress, and the use of medications during transition may affect maternal and/or fetal well-being during birth.

Answer to Question 2

ANS: A
The nurse's first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. The blood pressure is an important assessment to determine the extent of blood loss but is not the top priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position would not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding.

[c0205847]

TYSM

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