A nurse is assisting with the care of a client who is in labour. Which of the following findings should the nurse report to the provider?

Fetal heart rate 100/min for a 10-min period.

Contraction resting period 35 seconds.

Contraction lasting 85 seconds.

Four contractions in a 10-min period.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A fetal heart rate of 100/min for a 10-minute period is considered within the normal range. The normal fetal heart rate can range from 110 to 160 beats per minute, and a rate of 100 is not concerning.

Choice B rationale:

The resting period of a contraction refers to the time between contractions when the uterus is relaxed. A resting period of 35 seconds is also considered normal. In labor, the resting period between contractions allows the placenta to receive oxygen and nutrients, and 35 seconds is a rationaleable duration.

Choice C rationale:

A contraction lasting 85 seconds is abnormal and should be reported to the provider. Normally, contractions last around 60-90 seconds, but an 85-second contraction may indicate uterine hyperactivity or other issues that could potentially affect the well-being of both the mother and the baby.

Choice D rationale:

Having four contractions in a 10-minute period is considered normal during labor. In fact, an average pattern includes 3-5 contractions within a 10-minute window, so this finding is not a cause for concern.

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Correct Answer is B

Explanation

Choice A rationale:
0.25 mL - The nurse should not administer 0.25 mL because the available concentration of vitamin K injection is 1 mg/0.5 mL. To achieve the prescribed dose of 1 mg, administering only 0.25 mL would be insufficient.
Choice B rationale:
0.5 mL - This is the correct choice. The nurse should administer 0.5 mL of the vitamin K injection to deliver 1 mg of vitamin K, as the concentration of the injection is 1 mg/0.5 mL. By giving the full 0.5 mL, the newborn will receive the appropriate 1 mg dose.
Choice C rationale:
0.75 mL - Administering 0.75 mL would be excessive for the prescribed 1 mg dose of vitamin K. It is unnecessary to give a higher volume than required, as it could lead to potential adverse effects or wastage.
Choice D rationale:
1 mL - Similarly, administering the entire 1 mL of the vitamin K injection would result in doubling the prescribed dose, leading to potential overdose and adverse reactions. The nurse should avoid administering more than the necessary 0.5 mL.

A. Prepare for cesarean birth. B. Initiate an IV infusion of magnesium sulfate. C. Administer antibiotics. D. Request the RN to perform a cervical examination.

Correct Answer is A

Explanation

Choice A rationale :

Prepare for cesarean birth. The nurse should consider preparing for a cesarean birth as the client is at 39 weeks of gestation and has heavy vaginal bleeding. Heavy vaginal bleeding during pregnancy could indicate an emergency situation such as placental abruption or placenta previa, both of which can be life-threatening for the mother and the baby. In such cases, an emergency cesarean birth might be necessary to ensure the safety of both the client and the baby. Promptly preparing for the procedure will help expedite the process and prevent any delays in providing necessary medical care.

Choice B rationale

Initiate an IV infusion of magnesium sulfate. Magnesium sulfate is not indicated in this situation. Magnesium sulfate is commonly used in obstetrics, particularly in the management of preeclampsia and eclampsia to prevent seizures. However, the client's heavy vaginal bleeding suggests a different issue and magnesium sulfate would not address the underlying cause. Instead, the focus should be on identifying and managing the cause of the bleeding to ensure the best outcome for the client and the baby.

Choice C rationale

Administer antibiotics. Administering antibiotics is not the priority action in this scenario. Heavy vaginal bleeding in a pregnant client requires immediate attention to assess the cause and determine the appropriate course of action. While antibiotics may be necessary in some situations, they are not the first-line treatment for heavy vaginal bleeding during pregnancy. The nurse should focus on providing prompt and appropriate care to address the client's immediate needs.

Choice D rationale

Request the RN to perform a cervical examination. Performing a cervical examination may provide valuable information about the cause of the heavy vaginal bleeding. It can help determine if the bleeding is related to cervical changes, such as cervical dilation or effacement. The findings from the cervical examination, along with other assessments, will aid in making the most appropriate decisions regarding the client's care. However, it is not the only action that the nurse should take. In this critical situation, the nurse must prioritize immediate interventions to ensure the safety and well-being of the client and the baby.

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A nurse is assisting with the care of a client who is in labour. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer vitamin K 1 mg IM to a newborn. Available is vitamin K injection 1 mg/0.5 mL. How many mL should the nurse administer per dose?

Correct Answer is B

Explanation

A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is postpartum. Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

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