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 D
Explanation
Choice A rationale: While adequate rest and sleep are essential postpartum, the client's symptoms of feeling down and sad may be indicative of postpartum depression and should be further evaluated.
Choice B rationale: Counseling may be helpful, but the priority is to first assess and screen for postpartum depression before making additional recommendations.
Choice C rationale: While antidepressant medications might be necessary for postpartum depression, the initial step should be to assess and screen for depression using the appropriate tool.
Choice D rationale: The client's statement and symptoms raise concerns about possible postpartum depression. Using a postpartum depression screening tool will help the nurse assess the severity of the client's symptoms and determine the appropriate course of action.
Correct Answer is D
Explanation
Choice A rationale: While folic acid is important during pregnancy, this statement is not specifically related to dietary intake for breastfeeding mothers. Adequate folic acid intake is essential during pregnancy to prevent neural tube defects in the developing fetus.
Choice B rationale: This statement does not provide enough information and may not be appropriate for all breastfeeding mothers. The caloric needs of breastfeeding mothers can vary depending on their individual metabolism, activity level, and nutritional status.
Choice C rationale: Breastfeeding mothers require adequate protein intake to support their own nutritional needs and the production of breast milk. Decreasing protein intake is not advisable and may lead to nutritional deficiencies.
Choice D rationale: Breastfeeding mothers need to stay well-hydrated to maintain an adequate milk supply and to support their own health. Drinking enough fluids, preferably decaffeinated, is essential for breastfeeding moms.
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