A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider?

Contraction resting period 35 seconds

Heart rate 100/min for a 10-min period

Four contractions in a 10-min period

Co Contraction lasting 85 seconds

Answer and Explanation

The Correct Answer is D

The correct answer is Choice D: Contraction lasting 85 seconds.

Choice A rationale: A contraction resting period of 35 seconds is normal and expected during labor. The resting period allows the uterine muscle to relax and replenish its oxygen supply, which is essential for fetal well-being. The resting period also gives the client a chance to rest and cope with the pain of labor. A normal resting period ranges from 30 to 90 seconds, depending on the stage and phase of labor¹².

Choice B rationale: A heart rate of 100/min for a 10-min period is within the normal range for an adult. The normal resting heart rate for an adult is 60 to 100 beats per minute (bpm)³. During labor, the heart rate may increase due to factors such as pain, anxiety, dehydration, fever, or infection. However, a heart rate of 100/min is not considered a sign of distress or complication, unless it is accompanied by other symptoms such as chest pain, shortness of breath, or palpitations⁴⁵.

Choice C rationale: Four contractions in a 10-min period is a normal frequency for labor contractions. The frequency of contractions refers to how often they occur, measured from the beginning of one contraction to the beginning of the next. The normal frequency of contractions varies depending on the stage and phase of labor, but generally ranges from two to five contractions in 10 minutes¹².

Choice D rationale: A contraction lasting 85 seconds is too long and should be reported to the provider. The duration of contractions refers to how long they last, measured from the beginning to the end of one contraction. The normal duration of contractions ranges from 30 to 70 seconds, depending on the stage and phase of labor¹². A contraction lasting longer than 90 seconds is considered a prolonged contraction, which can reduce the blood flow and oxygen supply to the placenta and the fetus, leading to fetal hypoxia and acidosis. Prolonged contractions can also cause uterine rupture, placental abruption, or maternal hemorrhage .

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Correct Answer is D

Explanation

Choice A rationale: Ventricular septal defect (VSD) is a congenital heart defect and is not directly related to respiratory distress syndrome or respiratory acidosis.
Choice B rationale: Cesarean birth, while it can have other implications, is not a direct risk factor for respiratory distress syndrome or respiratory acidosis. The mode of delivery does not directly impact the newborn's respiratory function.
Choice C rationale: While being small for gestational age can be associated with certain health challenges, it is not a direct risk factor for respiratory distress syndrome or respiratory acidosis. The baby's size does not determine its respiratory status.
Choice D rationale: Maternal history of asthma is a risk factor that can predispose the newborn to respiratory difficulties, including respiratory distress syndrome (RDS) and respiratory acidosis. Infants born to mothers with asthma may have a higher likelihood of developing respiratory problems due to potential genetic factors and exposure to environmental triggers during pregnancy.

A. "I think you should call your minister. He can help comfort you." B. "It must be very difficult for you both. I will be available if you need anything." C. "You are both young and can have other children." D. "Did you have any complications during your pregnancy?"

Correct Answer is B

Explanation

Choice A rationale: This response assumes that the couple's religious beliefs are relevant to them, which may not be the case. It is not appropriate for the nurse to suggest involving their minister without knowing their preferences or beliefs.
Choice B rationale: This response acknowledges the couple's emotional experience and shows empathy toward their grief. It offers support and reassurance that the nurse will be available to help them through this difficult time.
Choice C rationale: While this statement may be factually true, it is not empathetic or supportive of the couple's current emotional state. It may come across as dismissive of their feelings and minimize their grief.
Choice D rationale: While gathering information about the pregnancy is essential for the medical record, this question does not address the couple's emotional needs. It is more appropriate to focus on offering emotional support and assistance rather than immediately delving into clinical details.

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A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

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