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 C

Explanation

Choice A rationale: Placing elbow restraints is not a recommended practice for preterm newborns. Restraints are used in some cases to prevent the baby from pulling on tubes or lines, but it is not primarily for energy conservation.
Choice B rationale: While frequent position changes are important to prevent pressure ulcers and promote comfort, they may not necessarily help conserve energy in a preterm newborn.
Choice C rationale: Preterm newborns have limited energy reserves, and conserving energy is essential for their growth and development. Clustering care activities involves combining nursing care tasks to allow for longer periods of uninterrupted rest for the baby. This approach reduces the baby's energy expenditure and promotes better weight gain and stability.
Choice D rationale: While gentle touch and massage can be beneficial for preterm newborns to promote bonding and relaxation, it may not directly conserve energy as cluster care does.

A. "Go to the emergency room and your provider will meet you the B. "Come to the office and we will check things out." C. "What else have you been eating?" D. "This is expected because of the way iron is broken down during digestion."

Correct Answer is D

Explanation

Choice A rationale:
Going to the emergency room for black stools without abdominal pain or cramping is not warranted in this situation.
Choice B rationale:
Having the client come to the office to check things out may not be necessary since black stools can be an expected side effect of iron supplements and do not necessarily indicate a problem.
Choice C rationale:
Asking about the client's diet is a valid question, but the black stools are likely due to iron supplements' effects and not related to dietary choices.
Choice D rationale:
Black stools are a known side effect of iron supplements. When iron is broken down during digestion, it can cause the stools to appear black or dark. As the client has no other concerning symptoms like abdominal pain or cramping, this response by the nurse reassures the client that the finding is expected and not a cause for alarm.

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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

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a preterm newborn. To help the newborn conserve energy, which of the following actions should the nurse recommend?

Correct Answer is C

Explanation

A nurse is speaking on the phone to a client on the phone who is pregnant and taking iron supplements for iron-deficiency anemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate?

Correct Answer is D

Explanation

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