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 B

Explanation

A. Incorrect. While using a disposable razor is a precaution for individuals taking anticoagulants to reduce the risk of bleeding, it is not specific to warfarin.
B. Correct. Taking oral contraceptives along with warfarin can increase the risk of bleeding.

Therefore, the client should be advised not to take oral contraceptives while on warfarin.

C. Incorrect. Aspirin is not typically recommended for pain relief in individuals taking warfarin due to the increased risk of bleeding.

D. Incorrect. The duration of warfarin therapy is individualized based on the specific condition being treated. It is not a fixed 2-week period.

A. Uterine atony B. Polyhydramnios C. Painless vaginal bleeding D. Board-like abdomen E. None F. None

Correct Answer is D

Explanation

A. Uterine atony
Uterine atony refers to the lack of muscle tone in the uterus after delivery, leading to excessive bleeding. This is not typically associated with abruptio placentae, which involves the premature separation of the placenta from the uterine wall during pregnancy, typically presenting with different symptoms such as painful contractions and bleeding.

B. Polyhydramnios
Polyhydramnios refers to an excessive amount of amniotic fluid during pregnancy and is not a characteristic of abruptio placentae. Polyhydramnios can be associated with various conditions but is not directly linked to placental abruption.

C. Painless vaginal bleeding
Painless vaginal bleeding is more characteristic of placenta previa, a condition where the placenta is abnormally positioned over the cervix. Abruptio placentae, on the other hand, typically presents with painful vaginal bleeding due to the detachment of the placenta from the uterine wall.

D. Board-like abdomen
A board-like abdomen is a classic sign of abruptio placentae, indicating significant uterine muscle contraction and possible internal hemorrhage. The sudden separation of the placenta can cause blood to accumulate behind the placenta, leading to a rigid, "board-like" feeling of the abdomen, which is a hallmark symptom of this condition.

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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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