A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?
Contractions occurring every 3 to 5 min
Each contraction lasting longer than 110 seconds
Contractions are strong in intensity
Client reports feeling contractions in lower back
The Correct Answer is B
Choice A reason: Contractions occurring every 3 to 5 min are normal and expected in the active phase of the first stage of labor, which lasts from 4 to 8 cm of cervical dilation. The nurse does not need to report this finding to the provider.
Choice B reason: Each contraction lasting longer than 110 seconds is abnormal and concerning, as it can indicate uterine hyperstimulation, which can reduce the blood flow to the placenta and fetus, and cause fetal distress. The nurse should report this finding to the provider immediately and prepare for interventions, such as stopping oxytocin infusion, administering tocolytics, or performing an emergency cesarean section.
Choice C reason: Contractions are strong in intensity are also normal and expected in the active phase of the first stage of labor, as they facilitate the cervical dilation and effacement. The nurse does not need to report this finding to the provider.
Choice D reason: Client reports feeling contractions in lower back are common and not harmful, especially if the fetus is in the occiput posterior position, which causes the fetal head to press against the sacrum. The nurse does not need to report this finding to the provider, but can offer comfort measures, such as massage, counterpressure, heat, or position changes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
To calculate the number of tablets, the nurse should use the following formula:
Number of tablets = (Desired dose / Available dose) x (Available form / Desired form)
In this case, the desired dose is 50 mg, the available dose is 100 mg, the available form is 1 tablet, and the desired form is 1 tablet. Therefore, the formula becomes:
Number of tablets = (50 mg / 100 mg) x (1 tablet / 1 tablet)
Number of tablets = 0.5 x 1
Number of tablets = 0.5
The nurse should round the answer to the nearest tenth, which is 0.5. The nurse should use a leading zero if the answer is less than 1, which is 0.5. The nurse should not use a trailing zero, which means 0.5 and not 0.50.
Correct Answer is A
Explanation
Choice A reason: A client who is experiencing preterm labor at 26 weeks of gestation is a suitable candidate for tocolytic therapy, because it can help delay the delivery and allow time for fetal lung maturation and transfer to a tertiary care center. Tocolytic therapy is indicated for clients who have regular uterine contractions and cervical changes before 37 weeks of gestation.
Choice B reason: A client who is experiencing fetal death at 32 weeks of gestation is not a suitable candidate for tocolytic therapy, because it has no benefit for the mother or the fetus. Tocolytic therapy is contraindicated for clients who have fetal demise, as it can increase the risk of infection and coagulation disorders.
Choice C reason: A client who has a post-term pregnancy at 42 weeks of gestation is not a suitable candidate for tocolytic therapy, because it can harm the mother and the fetus. Tocolytic therapy is contraindicated for clients who have post-term pregnancy, as it can increase the risk of placental insufficiency, fetal distress, and meconium aspiration.
Choice D reason: A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation is not a suitable candidate for tocolytic therapy, because it is not necessary or effective. Braxton-Hicks contractions are irregular and painless contractions that do not cause cervical changes or labor. They are normal and harmless, and do not require any intervention.
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