A nurse is assisting with the care of a client who is in the latent phase of labor and just had an amniotomy. Which of the following findings indicates that the fetus is at risk?
Recurrent variable deceleration of the FHR
Uterine contractions every 6 min
Uterine contractions lasting 30 to 45 seconds
Moderate variability of the FHR
The Correct Answer is A
A. Recurrent variable decelerations of the fetal heart rate (FHR) are concerning and can indicate fetal distress.
B. Uterine contractions every 6 minutes may not provide effective progress in labor, but it is not indicative of fetal distress.
C. Uterine contractions lasting 30 to 45 seconds are within the normal range for labor.
D. Moderate variability of the FHR is a reassuring sign and indicates that the fetus is tolerating labor well.
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Related Questions
Correct Answer is D
Explanation
A: Administering the medication into the deltoid muscle is not recommended for newborns due to their underdeveloped muscle mass and the potential for injury. The vastus lateralis muscle in the thigh is the preferred site for intramuscular injections in infants.
B: Checking the mother's Rh factor is not directly related to the administration of phytonadione, which is given to prevent vitamin K deficiency bleeding in the newborn, a condition unrelated to the mother's Rh factor.
C: Administering the medication 12 hours after birth is not the standard practice. Phytonadione is typically given within the first hour after birth to ensure prompt prevention of hemorrhagic disease of the newborn.
D: Administering the medication with a 25 gauge needle is appropriate as it is small enough to cause minimal discomfort and large enough to ensure proper delivery of the medication into the infant's muscle tissue.
Correct Answer is A
Explanation
A. Hyporeflexia is a significant adverse effect of magnesium sulfate therapy and can indicate magnesium toxicity. It is essential for the nurse to monitor deep tendon reflexes as part of the assessment when a client is receiving this medication. A decrease in reflexes may warrant immediate intervention and reporting to the provider.
B. Tachypnea is not a common adverse effect of magnesium sulfate; however, if it occurs, it may indicate respiratory distress, which should be assessed further.
C. Polyuria is not a typical adverse effect of magnesium sulfate. In fact, magnesium can lead to decreased urine output in some cases, especially with toxicity.
D. Agitation is also not a typical adverse effect of magnesium sulfate. Clients receiving magnesium sulfate may exhibit sedation rather than agitation.
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