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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Blunt force trauma is a possible risk factor for placental abruption, which is a condition where the placenta detaches from the uterine wall and causes bleeding, pain, and fetal distress. However, blunt force trauma is not the most common risk factor, as it accounts for only a small percentage of cases. The most common causes of blunt force trauma are motor vehicle accidents, falls, or domestic violence.

Choice B reason: Hypertension is the most common risk factor for placental abruption, as it affects about 50% of cases. Hypertension can cause vasospasm and reduced blood flow to the placenta, which can weaken the attachment and lead to separation. Hypertension can be chronic, gestational, or related to preeclampsia.

Choice C reason: Gestational diabetes mellitus is not a risk factor for placental abruption, but rather a condition where the client develops high blood sugar levels during pregnancy and can cause complications, such as macrosomia, polyhydramnios, or neonatal hypoglycemia. Gestational diabetes mellitus does not affect the placental attachment or function.

Choice D reason: Cigarette smoking is a risk factor for placental abruption, as it can cause vasoconstriction and reduced oxygen delivery to the placenta, which can impair its growth and development. However, cigarette smoking is not the most common risk factor, as it affects about 25% of cases.

A. Continuous fetal monitoring B. Ambulate to induce labor C. Obtain a daily weight D. Assess deep tendon reflexes every hour

Correct Answer is B

Explanation

Choice A reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause fetal distress, growth restriction, or demise. Continuous fetal monitoring can help detect and evaluate the fetal heart rate, variability, accelerations, decelerations, and contractions, and guide the management and intervention.

Choice B reason: This order requires clarification, as it is an inappropriate and contraindicated order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause seizures, stroke, or organ failure. Ambulation can increase the blood pressure, stimulate the labor, and worsen the condition. The client should be on bed rest, with the head of the bed elevated, and receive medications to lower the blood pressure and prevent seizures.

Choice C reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause edema, proteinuria, or oliguria. Obtaining a daily weight can help monitor the fluid status, the severity of the edema, and the response to the treatment.

Choice D reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause hyperreflexia, clonus, or seizures. Assessing deep tendon reflexes every hour can help evaluate the neuromuscular irritability, the risk of eclampsia, and the effect of magnesium sulfate.

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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?

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