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.
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 D
Explanation
Choice A rationale :
Contractions every 3 to 4 minutes. Rationale: Contractions are a significant sign of labor. When the uterus contracts regularly and with increasing intensity, it indicates that the woman is in labor. However, contractions alone may not be enough to confirm active labor, as Braxton Hicks contractions can occur earlier in pregnancy, which are often irregular and less intense.
Choice B rationale
Pain just above the navel. Rationale: Pain above the navel is not a specific indicator of labor. In late pregnancy, the baby's head may engage in the pelvis, causing pressure and discomfort in the upper abdomen. However, this symptom alone does not confirm active labor and can be attributed to various other factors as well.
Choice C rationale
Amniotic fluid in the vaginal vault. Rationale: The presence of amniotic fluid in the vaginal vault, also known as rupture of membranes or "water breaking,”. is a significant sign that labor is likely to be in progress or imminent. When the amniotic sac ruptures, it releases the fluid that surrounds the baby in the uterus. This is a clear indication of active labor.
Choice D rationale
Cervical dilation. Rationale: Cervical dilation is one of the most reliable signs of active labor. As the uterus contracts, the cervix starts to dilate and efface (thin out) to allow the baby's passage through the birth canal. Measuring cervical dilation during a pelvic examination provides valuable information about the progress of labor.
Correct Answer is C
Explanation
The correct answer is choice C. Assist the client to breathe into a paper bag.
Choice A rationale:
Instructing the client to maintain a breathing rate no less than twice the normal rate is not appropriate. This could exacerbate hyperventilation, leading to further lightheadedness and tingling.
Choice B rationale:
Administering oxygen via nasal cannula is not necessary in this situation. The symptoms are due to hyperventilation, not a lack of oxygen.
Choice C rationale:
Assisting the client to breathe into a paper bag helps to rebreathe carbon dioxide, which can correct the respiratory alkalosis caused by hyperventilation. This will alleviate the symptoms of lightheadedness and tingling.
Choice D rationale:
Having the client tuck her chin to her chest is not a recognized intervention for hyperventilation. It would not address the underlying issue of respiratory alkalosis.
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