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
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 .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: An increase in breast milk production is a normal physiological response during breastfeeding and does not indicate mastitis.
Choice B rationale: Mastitis is an inflammation of the breast tissue, usually caused by infection. It commonly occurs in breastfeeding women and is characterized by redness, warmth, swelling, and pain in one breast. The affected breast may also be tender and sore to the touch.
Choice C rationale: Swelling in both breasts is a common occurrence during the early days of breastfeeding as the milk supply adjusts to the baby's needs. It is not specific to mastitis.
Choice D rationale: Cracked and bleeding nipples can be a result of improper latch or positioning during breastfeeding, but they are not specific to mastitis.
Correct Answer is D
Explanation
Choice A rationale: This response is not supportive and may cause the client to feel pressured or inadequate. It is essential to be empathetic and understanding of the client's feelings and needs.
Choice B rationale: The nurse should encourage the client to begin breastfeeding and offer support if needed. This response does not promote the client's active involvement in caring for her newborn.
Choice C rationale: While breastfeeding is a natural process, it can be challenging for some women, especially in the early days. This response may minimize the client's concerns and emotions.
Choice D rationale: The nurse should be supportive and reassuring to the postpartum client. The client may be feeling overwhelmed or uncertain about breastfeeding, so offering assistance and staying with the client to help with the first feeding is an appropriate and compassionate response.
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