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 C
Explanation
Choice A rationale:
A gynaecoid pelvis is considered the most favorable pelvic shape for childbirth and is not a contributing cause of difficult, prolonged labor.
Choice B rationale:
A longitudinal fetal lie (baby's spine aligned with the mother's spine) is a normal and favorable presentation for birth and is not a contributing cause of difficult, prolonged labor.
Choice C rationale:
A persistent occiput posterior position (baby's head facing the mother's abdomen instead of her back) can be a contributing cause of difficult, prolonged labor and may lead to a severe backache for the mother.
Choice D rationale:
Fetal attitude in general flexion (baby's head flexed forward, chin to chest) is a normal and favorable presentation for birth and is not a contributing cause of difficult, prolonged labor.
Correct Answer is B
Explanation
Choice A rationale: A positive contraction stress test warrants immediate attention and evaluation. Waiting for 24 hours to repeat the test could delay necessary interventions in case of fetal distress.
Choice B rationale: A positive contraction stress test indicates that there are late decelerations in the baby's heart rate during contractions, which may suggest fetal distress. In such cases, it is essential to admit the client to the hospital for further evaluation, monitoring, and appropriate management.
Choice C rationale: Checking the client's cervix for dilation is not the most appropriate action in response to a positive contraction stress test. Fetal well-being and assessment take priority in this situation.
Choice D rationale: A positive contraction stress test requires further action and should not be considered a routine finding. Proper management and evaluation are necessary when the test results are positive.
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