A nurse is assisting with the cane of a labor and delivery unit
The nurse is contacting the provider regarding the client's status. Which of the following findings should the nurse include in the report?
Select the 4 findings that the nurse should report
Gestational age
Vaginal examination
Uterine contractions
Maternal blood pressure
Correct Answer : A,C,E,F
A. Gestational age: The client is 31 weeks of gestation, which is preterm. This is critical information to determine the risk for preterm labor and guide interventions such as corticosteroid administration for fetal lung maturity or tocolytic therapy.
B. Vaginal examination: While a vaginal examination can provide information on cervical dilation and effacement, it is not appropriate to perform without consulting the provider first, especially in a preterm client with contractions.
C. Uterine contractions: The frequency (every 10 minutes) and duration (lasting 30 seconds) of contractions are critical findings that suggest the possibility of preterm labor. This information helps the provider decide on appropriate diagnostic or therapeutic measures, such as starting a tocolytic or performing fetal monitoring.
D. Maternal blood pressure: The maternal blood pressure is within normal limits (118/78 mmHg) and does not indicate a pressing concern in this scenario.
E. Maternal report of pain: The client reports cramping and low back pain, which could indicate preterm labor or another issue affecting uterine activity. This subjective information helps the provider assess the need for further evaluation or pain relief measures.
F. Fetal heart rate: The FHR is 140 beats per minute, which is within the normal range (110-160 bpm). A normal FHR suggests that the fetus is not in distress, but continuous monitoring and assessment are necessary to ensure the fetus remains well-oxygenated, especially in the context of uterine contractions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Massaging the client's back: Activates larger nerve fibers, blocking pain signals to the brain, which aligns with the gate control theory.
B. Administering prescribed analgesic medication: Provides pharmacological pain relief but does not align with gate control theory principles.
C. Turning the client onto her left side: May improve comfort and circulation but does not directly engage the gate control mechanism.
D. Encouraging the client to rest between contractions: Helpful for overall labor management but unrelated to gate control theory.
Correct Answer is D
Explanation
A. Instruct the client to maintain a breathing rate no less than twice the normal rate: This does not correct the underlying issue of hyperventilation and may worsen symptoms.
B. Have the client tuck her chin to her chest: This does not address the symptoms of hyperventilation.
C. Administer oxygen via nasal cannula: Unnecessary, as the issue is not hypoxia but respiratory alkalosis from excessive exhalation of CO₂.
D. Assist the client to breathe into a paper bag: Rebreathing CO₂ corrects respiratory alkalosis, resolving lightheadedness and tingling.
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