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:
Uterine enlargement greater than expected for gestational age is not a typical finding in a possible ectopic pregnancy. An ectopic pregnancy occurs when the fertilized egg implants outside the uterus, usually in the fallopian tube, and the uterus does not enlarge normally.
Choice B rationale:
Copious vaginal bleeding is not a typical finding in a possible ectopic pregnancy. Vaginal bleeding can occur, but it is not usually copious.
Choice C rationale:
Severe nausea and vomiting are not typically associated with a possible ectopic pregnancy. Nausea and vomiting are common symptoms in early pregnancy, but they are not specific to an ectopic pregnancy.
Choice D rationale:
Pelvic pain is a common finding in a possible ectopic pregnancy. The pain is often sharp, and unilateral, and may be located on one side of the lower abdomen or pelvis.

A. "This test determines if kernicterus will occur in the newborn." B. "This test detects Rh-positive antibodies in the mother's blood." C. "This test detects Rh-negative antibodies in a newborn who is Rh-positive." D. "This test determines the presence of maternal antibodies in the newborn's blood."

Correct Answer is C

Explanation

Choice A rationale: Kernicterus is a severe form of jaundice that can result from untreated hyperbilirubinemia in a newborn. The indirect Coombs test does not assess the risk of kernicterus specifically.
Choice B rationale: The indirect Coombs test detects Rh-negative antibodies in the mother's blood, not Rh-positive antibodies.
Choice C rationale: The indirect Coombs test, also known as the indirect antiglobulin test (IAT), is performed on a pregnant woman to detect the presence of Rh-negative antibodies in her blood. If the mother is Rh-negative and has been sensitized to Rh-positive blood, these antibodies can cross the placenta and attack the red blood cells of an Rh-positive fetus, potentially causing hemolytic disease of the newborn (HDN) or erythroblastosis fetalis.
Choice D rationale: The direct Coombs test (direct antiglobulin test) is used to detect the presence of maternal antibodies that have already been attached to the newborn's red blood cells. The indirect Coombs test is used to identify the presence of these antibodies in the mother's blood before they have attached to the newborn's red blood cells.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about the purpose of an indirect Coombs test. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

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