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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Related Questions
Correct Answer is D
Explanation
A. Contraction resting period 35 seconds: A resting period of 35 seconds is within normal limits and allows uterine relaxation.
B. Four contractions in a 10-min period: This contraction frequency is normal for active labor.
C. Contraction lasting 85 seconds: A contraction duration of up to 90 seconds is typical in active labor, though the nurse should monitor for patterns of tachysystole.
D. Fetal heart rate 100/min for a 10-min period: A sustained FHR of 100/min is bradycardia and indicates fetal distress, requiring immediate evaluation and intervention.
Correct Answer is B
Explanation
A. The nurse will initiate any prior to this test: Nurses do not initiate this test; it is ordered by a provider and performed using ultrasound and sometimes non-stress tests.
B. The test predicts fetal well-being in the third trimester: A biophysical profile (BPP) evaluates fetal health by assessing parameters such as fetal movements, breathing, amniotic fluid volume, and heart rate.
C. The client will need to be NPO prior to the test: There are no dietary restrictions for a BPP.
D. This test determines the estimated date of birth: BPP is not used to estimate gestational age or determine an EDB. It assesses fetal well-being.
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