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: This statement is incorrect, as it is not the definition of polyhydramnios, but rather a possible cause of it. Polyhydramnios is a condition where the amniotic fluid volume exceeds 2,000 mL at term, or the amniotic fluid index (AFI) is greater than 25 cm. Polyhydramnios can occur in multiple pregnancies, as the fetuses produce more urine and fluid than a single fetus.
Choice B reason: This statement is incorrect, as it is not the definition of polyhydramnios, but rather a possible complication of it. Polyhydramnios can cause fetal anomalies, such as esophageal atresia, anencephaly, or neural tube defects, which impair the swallowing or absorption of the amniotic fluid. Polyhydramnios can also cause fetal growth restriction or distress, as the excess fluid can compress the umbilical cord or the placenta, and reduce the blood flow and oxygen delivery to the fetus.
Choice C reason: This statement is correct, as it is the definition of polyhydramnios, which is a condition where the amniotic fluid volume exceeds 2,000 mL at term, or the amniotic fluid index (AFI) is greater than 25 cm. Polyhydramnios can be diagnosed by ultrasound, and it can cause maternal and fetal complications, such as preterm labor, premature rupture of membranes, placental abruption, or cord prolapse.
Choice D reason: This statement is incorrect, as it is not the definition of polyhydramnios, but rather a marker of fetal anomalies. Alpha-fetoprotein (AFP) is a protein that is produced by the fetus, and it can be measured in the maternal serum or the amniotic fluid. An elevated level of AFP in the amniotic fluid can indicate fetal anomalies, such as neural tube defects, abdominal wall defects, or renal anomalies, which can cause polyhydramnios.
Correct Answer is A
Explanation
Choice A reason: This action is the first and most important intervention that the nurse should perform, as it can prevent or reduce the compression of the umbilical cord, which can cause fetal hypoxia, bradycardia, or death. The nurse should insert a gloved hand into the vagina and gently push the presenting part away from the cord, and maintain this position until the delivery.
Choice B reason: This action is not the first intervention that the nurse should perform, as it does not address the cause of the cord prolapse, which is the displacement of the cord below the presenting part. However, this action is helpful to prevent the drying and infection of the cord, and should be done after the first intervention.
Choice C reason: This action is not the first intervention that the nurse should perform, as it may not be effective or feasible depending on the stage of labor and the client's condition. However, this action is beneficial to reduce the pressure of the presenting part on the cord, and should be done after the first intervention.
Choice D reason: This action is not the first intervention that the nurse should perform, as it does not provide immediate relief or protection to the fetus. However, this action is necessary to expedite the delivery and prevent further complications, and should be done after the first intervention.
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