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 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.
Correct Answer is B
Explanation
Choice A reason: Reinforcing postpartum and newborn care discharge teaching is not a priority action by the nurse, as it is not directly related to the client's emotional state or safety. Reinforcing postpartum and newborn care discharge teaching is an important intervention that can help the client to manage her physical recovery and her infant's needs, but it is not sufficient to address the client's symptoms of postpartum depression, which is a mood disorder that can affect the client's mental health and well-being.
Choice B reason: Asking the client if she has considered harming her newborn is a priority action by the nurse, as it is essential to assess the client's risk of infanticide, which is the intentional killing of an infant by the mother. Asking the client if she has considered harming her newborn is a sensitive and difficult question, but it is necessary to ensure the safety of the infant and the mother, and to provide appropriate interventions and referrals. The nurse should ask the question in a nonjudgmental and supportive manner, and validate the client's feelings and concerns.
Choice C reason: Assisting the family to identify prior use of positive coping skills in family crises is not a priority action by the nurse, as it is not directly related to the client's emotional state or safety. Assisting the family to identify prior use of positive coping skills in family crises is a helpful intervention that can enhance the client's resilience and self-efficacy, but it is not sufficient to address the client's symptoms of postpartum depression, which is a mood disorder that can affect the client's mental health and well-being.
Choice D reason: Anticipating a prescription by the provider for an antidepressant is not a priority action by the nurse, as it is not directly related to the client's emotional state or safety. Anticipating a prescription by the provider for an antidepressant is a possible intervention that can improve the client's mood and functioning, but it is not the only or the first option to address the client's symptoms of postpartum depression, which is a mood disorder that can affect the client's mental health and well-being. The nurse should collaborate with the provider and the client to determine the best treatment plan, which may include psychotherapy, social support, or alternative therapies.
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