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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 B

Explanation

Choice A rationale:

Informing the family of the need for information is important, but it is not the most important aspect when working with a family who suspects they could bear a child with a genetic abnormality.

Choice B rationale:

Presenting the information in a factual, nondirective manner is the most important aspect. This allows the family to make informed decisions based on accurate information without being influenced by the nurse’s personal beliefs or opinions.

Choice C rationale:

Maintaining the confidentiality of the information is a standard nursing practice and while it is important, it is not the most important aspect in this scenario.

Choice D rationale:

Gathering information for three generations can provide valuable insight into the family’s genetic history, but it is not the most important aspect in this scenario.

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?.

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Naxlex Comprehensive Predictor Exams

The nurse is counseling a couple who suspect that they could bear a child with a genetic abnormality. What would be most important for the nurse to do when working with this family?.

Correct Answer is B

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?.