Labor And Postpartum Client Monitoring - NCLEX Pn
- What is the priority action when the postpartum uterus is deviated to the right?
- Assist the client to void (suspect bladder distention). Deviation suggests bladder fullness displacing the uterus, impeding involution and increasing bleeding risk.
- What is the immediate nursing action after spontaneous rupture of membranes?
- Assess fetal heart rate for cord prolapse. Rupture increases risk of cord descent and compression, necessitating prompt FHR assessment for bradycardia.
- What baseline FHR finding is classified as fetal bradycardia?
- Baseline FHR <110 bpm for at least 10 minutes. Persistent low rate suggests potential fetal hypoxia, acidosis, or congenital heart issues requiring intervention.
- Which assessment finding suggests postpartum endometritis?
- Fever after 24 hours with uterine tenderness and foul lochia. These symptoms indicate bacterial infection of the endometrium, often from ascending pathogens post-delivery.
- What is the expected postpartum temperature variation within the first 24 hours?
- May be up to 38°C (100.4°F) in first 24 hours. Mild elevation results from labor exertion and dehydration, considered physiologic if resolving without infection signs.
- What is the normal baseline fetal heart rate (FHR) range in labor?
- Normal FHR baseline is 110–160 bpm. This range reflects fetal well-being per NICHD guidelines, indicating adequate oxygenation and autonomic function during labor.
- What is the definition of a late deceleration pattern on FHR monitoring?
- Decel begins after contraction starts; nadir after peak. This pattern indicates uteroplacental insufficiency, where decreased oxygen delivery during contractions causes delayed fetal heart rate recovery.
- Which oxygen delivery method is used for intrauterine resuscitation when ordered?
- Nonrebreather mask at 10 L/min. This method provides high-flow oxygen to enhance maternal hemoglobin saturation and fetal oxygen transfer across the placenta.
- What is the definition of an early deceleration pattern on FHR monitoring?
- Decel mirrors contraction; nadir at contraction peak. This benign pattern results from vagal stimulation due to fetal head compression during contractions.
- What is the definition of a variable deceleration pattern on FHR monitoring?
- Abrupt decel with variable timing; often cord compression. These decelerations are caused by transient umbilical cord compression, leading to abrupt drops unrelated to contraction timing.
- What baseline FHR finding is classified as fetal tachycardia?
- Baseline FHR >160 bpm for at least 10 minutes. Elevated rate often indicates maternal fever, infection, or fetal stress, classified as a Category II feature.
- Which assessment best confirms rupture of membranes at bedside?
- Nitrazine or ferning test of vaginal fluid. Nitrazine detects alkaline amniotic fluid via pH change, while ferning shows characteristic crystallization under microscopy.
- Which intervention is appropriate for uterine tachysystole with nonreassuring FHR?
- Stop oxytocin infusion. Discontinuing oxytocin reduces excessive uterine activity, allowing fetal recovery from compromised oxygenation.
- Which finding most strongly suggests postpartum hemorrhage requiring rapid response?
- Saturated perineal pad in 1 hour or less. Rapid saturation signals excessive blood loss, often from uterine atony, requiring immediate intervention to prevent shock.
- What is the expected uterine fundus location immediately after birth?
- At or near the umbilicus, firm and midline. Post-delivery involution places the fundus at this level, with firmness indicating effective contraction to control bleeding.
- What is the expected maternal blood pressure change after epidural anesthesia?
- Hypotension is a common adverse effect. Epidural-induced sympathectomy causes vasodilation, reducing preload and blood pressure in laboring clients.
- What is the definition of moderate FHR variability (Category I feature)?
- Amplitude range 6–25 bpm around baseline. This variability level is reassuring, reflecting intact fetal central nervous system and autonomic regulation.
- What postpartum finding is most consistent with deep vein thrombosis (DVT)?
- Unilateral leg pain, warmth, swelling, and tenderness. These localized signs reflect venous inflammation and thrombosis, heightened by postpartum hypercoagulability.
- What finding indicates adequate uterine resting tone on external tocodynamometer?
- Resting tone is soft/relaxed by palpation between contractions. Soft tone ensures adequate placental reperfusion between contractions, preventing fetal distress from hyperstimulation.
- What is the definition of absent FHR variability?
- Undetectable amplitude range around baseline. Absence of fluctuations may signal fetal acidosis, CNS depression, or medication effects, warranting urgent evaluation.
- Which action is indicated for a boggy uterus with heavy lochia postpartum?
- Perform firm fundal massage. Massage stimulates uterine contraction, expelling clots and reducing hemorrhage risk from atony.
- What is the priority nursing action for a prolapsed umbilical cord?
- Elevate presenting part off cord and call for help. Manual elevation relieves cord compression to restore fetal circulation while summoning assistance for emergent delivery.
- What lochia finding is expected in the first 24 hours postpartum?
- Lochia rubra: dark red, bloody flow. Initial lochia consists of blood and decidua from uterine shedding, transitioning to serosa after 3-4 days.
- What is the first nursing action for recurrent late decelerations?
- Reposition client to lateral side-lying. Changing position relieves inferior vena cava compression, improving maternal cardiac output and uteroplacental perfusion.
- What is the definition of uterine tachysystole during labor?
- More than 5 contractions in 10 minutes (averaged over 30). Excessive contractions reduce intervillous blood flow, potentially causing fetal hypoxia if prolonged.