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A nurse is assessing a woman in labor.
Which finding would the nurse identify as a cause for concern during a contraction?.

Blood pressure rise from 110/60 mm Hg to 120/74.

White blood cell count of 12,000 cells/mm.

Respiratory rate of 10 breaths/minute.

Heart rate increase from 76 bpm to 90 bpm.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A slight increase in blood pressure during contractions is normal.

Choice B rationale:

A white blood cell count of 12,000 cells/mm is within the normal range.

Choice C rationale:

A respiratory rate of 10 breaths/minute is low and could indicate respiratory depression.

Choice D rationale:

A heart rate increase from 76 bpm to 90 bpm is within the normal range.

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Correct Answer is D

Explanation

Choice A rationale:

A respiratory rate of 10 breaths/minute is low and could indicate magnesium toxicity.

Choice B rationale:

Difficulty in arousing could also indicate magnesium toxicity.

Choice C rationale:

Urinary output of 20 mL per hour is low and could indicate renal impairment.

Choice D rationale:

Deep tendon reflexes of 2+ would be considered normal and therefore a therapeutic level of the drug.

A. Obtain assistance to check for a compressed umbilical cord. B. Prepare the woman for an emergency cesarean birth. C. Document the finding. D. Help the woman change positions.

Correct Answer is D

Explanation

Choice A rationale:

Checking for a compressed umbilical cord is important as it can cause fetal distress. However, it’s not the first step in response to abnormal EFM tracing.

Choice B rationale:

Preparing for an emergency cesarean birth might be necessary if the abnormality persists and indicates fetal distress. But it’s not the immediate first step.

Choice C rationale:

Documenting the finding is part of the nursing process, but immediate interventions to address the abnormality take precedence.

Choice D rationale:

Helping the woman change positions can relieve pressure on the umbilical cord, potentially resolving the abnormality. This is often the first intervention.

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A nurse is assessing a woman in labor. Which finding would the nurse identify as a cause for concern during a contraction?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?.

Correct Answer is D

Explanation

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention?

Correct Answer is D

Explanation

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A nurse is assessing a woman in labor.
Which finding would the nurse identify as a cause for concern during a contraction?.