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

Answer and Explanation

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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Correct Answer is A

Explanation

A. 2+ ketonuria indicates an elevated level of ketones in the urine, which can be a sign of inadequate nutrition or metabolism. This should be reported to the provider for further evaluation.
B. A urine specific gravity of 1.030 is within normal range during pregnancy.
C. A hematocrit (Hct) of 38% is within the normal range for a pregnant individual.
D. A fasting blood glucose level of 70 mg/dL is within the normal range.

A. Apply elastic stockings before the client gets out of bed. B. Apply warm, moist packs to the client's lower legs. C. Have the client ambulate as often as possible. D. Administer NSAIDs every 4 to 6 hours.

Correct Answer is C

Explanation

A: Elastic stockings are used to promote venous return and decrease the risk of thrombosis, but they are not the primary preventive measure against thrombophlebitis.

B: Warm, moist packs may provide comfort and reduce localized swelling, but they do not prevent thrombophlebitis and are not a standard preventive measure.

C: Early and frequent ambulation is the most effective way to prevent thrombophlebitis. It enhances blood flow and prevents stasis, which is a major risk factor for the development of thrombophlebitis.

D: NSAIDs can be used to manage pain and inflammation but are not used as a preventive measure for thrombophlebitis in the postpartum setting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

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