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 ["200"]
Explanation
The correct answer is 200 mL/hr.
To calculate the IV rate, the nurse should use the following formula:
IV rate (mL/hr) = (Volume to be infused (mL) / Time of infusion (hr)) x Drop factor (gtt/mL)
In this case, the volume to be infused is 100 mL, the time of infusion is 0.5 hr (30 min), and the drop factor is 1 gtt/mL (assuming the IV pump is calibrated in mL/hr). Therefore, the formula becomes:
IV rate (mL/hr) = (100 mL / 0.5 hr) x 1 gtt/mL
IV rate (mL/hr) = 200 mL/hr
The nurse should round the answer to the nearest whole number, which is 200 mL/hr. The nurse should use a leading zero if the answer is less than 1, which is not the case here. The nurse should not use a trailing zero, which means 200 mL/hr and not 200.0 mL/hr.
Correct Answer is C
Explanation
Choice A reason: Physiological jaundice is not the correct answer, as it is a normal and benign condition that occurs in about 60% of term newborns, and usually appears after the first 24 hours of life. Physiological jaundice is caused by the breakdown of fetal hemoglobin and the immature liver function, and resolves within a few days.
Choice B reason: Maternal cocaine abuse is not the correct answer, as it is a maternal risk factor that can cause various complications in the newborn, such as low birth weight, prematurity, intrauterine growth restriction, or congenital anomalies. Maternal cocaine abuse does not cause jaundice in the newborn, unless it leads to hepatic or renal dysfunction.
Choice C reason: Maternal/newborn blood group incompatibility is the correct answer, as it is a maternal-fetal condition that can cause hemolytic disease of the newborn, which is a severe form of jaundice that can appear within the first 24 hours of life. Maternal/newborn blood group incompatibility occurs when the mother's blood type is Rh negative and the newborn's blood type is Rh positive, or when the mother's blood type is O and the newborn's blood type is A or B. The maternal antibodies cross the placenta and attack the newborn's red blood cells, causing hemolysis, anemia, and hyperbilirubinemia.
Choice D reason: Absence of vitamin K is not the correct answer, as it is a nutritional deficiency that can cause hemorrhagic disease of the newborn, which is a bleeding disorder that can occur within the first week of life. Absence of vitamin K is due to the lack of intestinal flora and the low vitamin K content in breast milk, and can cause bleeding in the skin, mucous membranes, or internal organs. Absence of vitamin K does not cause jaundice in the newborn, unless it leads to hepatic or biliary dysfunction.
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