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 lasting 85 seconds
Contraction resting period 35 seconds
Heart rate 100/min for a 10-min period
One contraction in a 10-min period
The Correct Answer is A
Choice A rationale:
Contraction duration: Contractions that last longer than 75 seconds are considered abnormal and should be reported to the
provider. This is because prolonged contractions can decrease oxygen supply to the fetus, leading to fetal distress.
Risk of uterine rupture: Excessively long contractions can also increase the risk of uterine rupture, a serious complication that
can endanger both the mother and the fetus.
Signs of fetal distress: The nurse should closely monitor the fetal heart rate for any signs of distress, such as late decelerations,
decreased variability, or bradycardia.
Need for intervention: If the contractions remain prolonged or if fetal distress is detected, the provider may need to intervene
to ensure the safety of both the mother and the fetus. This could involve measures such as administering medications to stop
or slow down labor, or performing a cesarean delivery.
Choice B rationale:
Contraction resting period: A contraction resting period of 35 seconds is within the normal range. Ideally, the resting period
between contractions should be at least 60 seconds, but it can vary. However, a resting period shorter than 30 seconds could
be a sign of tachysystole (excessively frequent contractions), which may also require intervention.
Choice C rationale:
Maternal heart rate: A maternal heart rate of 100 beats per minute is considered normal during labor. Heart rate can increase
with exertion, pain, and anxiety, which are common during labor. However, it's important to monitor for significant
tachycardia (heart rate over 120 beats per minute), which could indicate underlying issues such as dehydration or infection.
Choice D rationale:
Contraction frequency: One contraction in a 10-minute period is not indicative of active labor. Labor is typically defined as
having regular contractions that are 5 minutes apart or less, lasting for 45-60 seconds each, and causing progressive cervical
change. In early labor, contractions may be more sporadic and less intense.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale:
Performing hand hygiene before and after voiding is crucial in preventing perineal infection. Hand hygiene is the most
effective way to prevent the spread of infections, including those that can infect the perineum.
Choice B rationale:
Cleaning the perineal area from front to back is a standard recommendation to prevent infection. This method ensures that
bacteria from the anal area are not spread to the vagina and urethra, which can cause urinary tract infections.
Choice C rationale:
Sitting on an inflatable donut is not typically recommended for the prevention of perineal infection. While it can provide
comfort for those with perineal pain, especially after childbirth, it does not directly contribute to the prevention of infection.
Choice D rationale:
Applying ice packs to the perineal area several times daily can help reduce swelling and provide pain relief, especially after a
vaginal birth. While it does not directly prevent infection, it can promote healing and comfort, which can indirectly help
prevent infection.
Choice E rationale:
Blotting the perineal area dry after voiding is another important step in preventing perineal infection. Keeping the area dry
prevents the growth of bacteria and other microbes that thrive in moist environments.
Correct Answer is B
Explanation
Choice A is incorrect. Preterm labor is defined as uterine contractions that occur before 37 weeks of gestation. The
client in this case is at 38 weeks of gestation, which is considered term gestation. Therefore, preterm labor is not the
most likely condition the client is experiencing.
Rationale for Choice B
Choice B is partially correct. While bed rest may be recommended for some clients experiencing certain conditions
during pregnancy, it is not the most appropriate intervention for all clients at 38 weeks of gestation. Additionally,
administering medication without knowing the specific condition the client is experiencing is not safe or ethical.
Rationale for Choice C
Choice C is correct. Monitoring contraction frequency and fetal heart rate are two of the most important actions a
nurse can take to assess a client at 38 weeks of gestation. These parameters can provide valuable information about
the client's progress and help to identify any potential problems.
Explanation:
At 38 weeks of gestation, the client is considered to be at term. This means that she is full-term and her baby is ready
to be born. However, even at term, there are a number of conditions that can occur that may require nursing
intervention.
One of the most common conditions that can occur at term is labor. Labor is the process by which the uterus contracts
and dilates to push the baby out of the birth canal. The nurse should monitor the client for signs and symptoms of
labor, such as:
Regular contractions that are becoming stronger and closer together
Bloody show (mucus mixed with blood)
Rupture of membranes (breaking of water)
If the nurse suspects that the client is in labor, she should notify the healthcare provider immediately.
Another condition that can occur at term is preeclampsia. Preeclampsia is a serious condition that can cause high
blood pressure, protein in the urine, and swelling in the face, hands, and feet. If the nurse suspects that the client has
preeclampsia, she should monitor the client's blood pressure, protein levels in the urine, and weight. She should also
notify the healthcare provider immediately.
In addition to monitoring for these specific conditions, the nurse should also perform a general assessment of the
client's health. This includes taking the client's vital signs, checking her abdomen for fetal movement, and listening to
the baby's heartbeat.
By monitoring the client for signs and symptoms of these conditions, the nurse can help to ensure a safe and healthy
delivery for both the mother and the baby.
Therefore, the two most important actions the nurse should take are:
Monitor the client for signs and symptoms of labor and preeclampsia.
Perform a general assessment of the client's health.
The two most important parameters the nurse should monitor are:
Contraction frequency and intensity
Fetal heart rate
By following these steps, the nurse can provide the best possible care for the client and her baby.
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