A nurse is assisting in the care of a client who is in the second stage of labor. Which of the following findings should the nurse report to the provider?
Early decelerations in the FHR.
Pelvic pressure with contractions.
Bloody show from the vagina.
Uterine contraction lasting 2 min.
The Correct Answer is D
The correct answer is choice D. Uterine contraction lasting 2 min.
Choice A rationale:
Early decelerations in the FHR are usually not a concern during the second stage of labor. They are a normal physiological response to the compression of the fetal head during contractions and are generally considered benign.
Choice B rationale:
Pelvic pressure with contractions is a normal finding during the second stage of labor as the baby descends into the pelvis. It does not typically require reporting to the provider unless it is associated with other concerning symptoms.
Choice C rationale:
A bloody show from the vagina is a common and expected finding during the second stage of labor. It indicates that the cervix is dilating and effacing, which is a normal part of the labor process.
Choice D rationale:
A uterine contraction lasting 2 minutes is abnormal and could indicate uterine tachysystole, which can lead to fetal distress due to reduced uterine blood flow and oxygen to the fetus. This finding should be reported to the provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
This statement is incorrect because Rho(D) immune globulin does not destroy Rh antibodies in a newborn who is Rh-positive. Instead, it acts to prevent the development of Rh antibodies in the mother.
Choice B rationale:
This statement is also incorrect. Rho(D) immune globulin does not destroy Rh antibodies in a woman who is Rh-negative. It is given to Rh-negative women to prevent them from forming Rh antibodies in response to Rh-positive fetal blood during pregnancy.
Choice C rationale:
This is the correct choice. Rho(D) immune globulin is given to Rh-negative women to prevent the formation of Rh antibodies. If an Rh-negative woman is exposed to Rh-positive blood (usually during childbirth), her immune system may recognize the Rh antigen as foreign and start producing Rh antibodies. These antibodies could potentially cross the placenta during a subsequent pregnancy and attack the red blood cells of an Rh-positive fetus, causing hemolytic disease in the newborn. Rho(D) immune globulin helps prevent this sensitization process.
Choice D rationale:
This statement is incorrect. Rho(D) immune globulin does not prevent the formation of Rh antibodies in a newborn who is Rh-positive. Its main purpose is to protect Rh-negative women from forming antibodies that could harm future Rh-positive pregnancies.
Correct Answer is C
Explanation
Choice C rationale:
This response is correct because black stools are a common side effect of taking iron supplements. Iron can cause the stool to appear black or
tarry due to the way it is broken down during digestion. It does not necessarily indicate a serious issue, especially if the client is not experiencing any abdominal pain or cramping. Educating the client about this expected side effect helps alleviate any concerns they might have about the change in stool colour.
Choice A rationale:
"Go to the emergency room and your provider will meet you there.”. This response is not appropriate in this situation. The client's report of black stools without abdominal pain or cramping is likely due to the iron supplements and does not warrant a visit to the emergency room. This response may cause unnecessary panic and anxiety for the client.
Choice B rationale:
"What else have you been eating?.”. This response is also not the best choice. While it's essential for healthcare providers to gather comprehensive information about a client's diet and lifestyle, in this case, the client's black stools can be directly attributed to the iron supplements. Focusing on other dietary factors might distract from addressing the client's concern about the side effect of iron supplementation.
Choice D rationale:
"Come to the office, and we will check things out.”. This response is not the most appropriate one either. A visit to the office might not be necessary solely based on the client's report of black stools without accompanying pain or cramping. This situation can be managed through education, and the client can be reassured that it is a typical side effect of iron supplements. An unnecessary visit to the office could inconvenience the client and waste both their time and the healthcare provider's time.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
