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

Umbilical cord compression

Head compression

Maternal opioid administration

Lateral deceleration

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Umbilical cord compression is a serious condition that can deprive the fetus of oxygen and nutrients. It can occur during labor

due to various factors, such as excessive fetal movement, a long umbilical cord, or decreased amniotic fluid.

Key signs of umbilical cord compression include:

Variable decelerations: These are abrupt decreases in the fetal heart rate (FHR) that vary in duration, depth, and timing. They

are often caused by cord compression, as the compression temporarily reduces blood flow to the fetus.

Late decelerations: These are delayed decreases in the FHR that occur after the peak of a uterine contraction. They can also be

a sign of cord compression, as the compression can impair placental blood flow.

Loss of FHR variability: This refers to a decrease in the normal fluctuations of the FHR. It can be a sign of fetal distress,

including cord compression.

Immediate action is crucial when umbilical cord compression is suspected. The nurse should:

Notify the provider immediately.

Change the mother's position: This can help relieve pressure on the cord. Common positions include:

Lateral positioning (lying on the side)

Trendelenburg position (lying on the back with the head tilted down)

Knee-chest position (kneeling with the chest on the bed)

Administer oxygen to the mother: This can increase fetal oxygenation.

Prepare for possible interventions: These may include amnioinfusion (infusing fluid into the amniotic sac to increase fluid

volume), internal fetal monitoring, or cesarean delivery.

Choice B rationale:

Head compression is a common occurrence during labor as the fetal head descends through the birth canal. It usually does not

require intervention unless it causes significant changes in the FHR or other signs of fetal distress.

Choice C rationale:

Maternal opioid administration can affect the FHR, but it is not typically a cause for immediate concern unless there are

significant changes in the FHR or other signs of fetal distress. The nurse should continue to monitor the FHR closely and report

any concerns to the provider.

Choice D rationale:

Lateral decelerations are not a recognized pattern of fetal heart rate decelerations. The correct term for decelerations that

occur after the peak of a contraction is "late decelerations."

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Correct Answer is C

Explanation

The correct answer is choice c. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines.

Choice A rationale:

This choice incorrectly states that the cervix is effaced 3 cm and dilated 30%. Effacement is measured in percentages, not centimeters, and dilation is measured in centimeters, not percentages.

Choice B rationale:

This choice correctly states the cervix is dilated 3 cm and effaced 30%, but it incorrectly states that the presenting part is 1 cm below the ischial spines. A station of -1 means the presenting part is 1 cm above the ischial spines.

Choice C rationale:

This choice correctly states that the cervix is dilated 3 cm, effaced 30%, and the presenting part is 1 cm above the ischial spines. This matches the documentation provided.

Choice D rationale:

This choice incorrectly states that the cervix is effaced 3 cm and dilated 30%. Effacement is measured in percentages, not centimeters, and dilation is measured in centimeters, not percentages. Additionally, it incorrectly states that the presenting part is 1 cm below the ischial spines. A station of -1 means the presenting part is 1 cm above the ischial spines.

A. Fundus at umbilicus level B. Urinary output 3,000 mL C. Temperature 100.4 F for two days D. Cesarean section shortly following delivery

Correct Answer is B

Explanation

Choice A rationale:

The fundus at the umbilicus level is a normal finding in the immediate postpartum period. After delivery, the top of the uterus

(known as the fundus) is typically at the level of the umbilicus. In the days following delivery, the uterus begins to shrink and

descend into the pelvic cavity, guided by the process known as involution.

Choice B rationale:

A urinary output of 3,000 mL is unusually high and could indicate a postpartum complication. Postpartum diuresis is common

as the body eliminates excess fluid accumulated during pregnancy. However, excessive urinary output could be a sign of

postpartum complications such as postpartum preeclampsia, which can occur after the birth of the baby and is characterized

by high blood pressure and signs of damage to another organ system, often the kidneys.

Choice C rationale:

A temperature of 100.4 F for two days postpartum can be a normal finding. It’s not uncommon for women to experience a

slight elevation in temperature in the first 24 hours after delivery due to the exertion of labor. However, a temperature above100.4 F beyond the first 24 hours could indicate an infection and should be evaluated.

Choice D rationale:
A cesarean section shortly following delivery is not typically a sign of a postpartum complication. It’s a surgical procedure used to deliver the baby and can be planned or unplanned due to various reasons such as the baby’s position, multiple pregnancies, or complications during labor. However, like any surgery, a cesarean section does carry risks and can increase the likelihood of certain postpartum complications such as infection or blood clots.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is in labor. The doctor documents the vaginal examination as: 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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