A nurse receives report about a client who is in labor and is having contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?
Contractions that last 45 seconds each with a 3 min rest between contractions
Contractions that last for 60 seconds each with a 3-min rest between contractions
Contractions that last for 60 seconds each with a 4-min rest between contractions
A contraction that lasts 4 min followed by a period of relaxation
The Correct Answer is B
A. Contractions that last 45 seconds each with a 3-minute rest between contractions are less common. Typically, contractions last around 60 seconds during active labor.
B. Contractions that last for 60 seconds each with a 3-min rest between contractions is the expected pattern.
During active labor, contractions are commonly around 60 seconds in duration, and they occur approximately every 4-5 minutes.
C. Contractions that last for 60 seconds each with a 4-min rest between contractions are not consistent with the usual pattern of contractions in active labor. A 4-minute rest between contractions would be an extended interval.
D. A contraction that lasts for 4 minutes followed by a period of relaxation is not typical and may indicate a problem. Normal contractions usually last around 60 seconds or less.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
"I will receive this medication if my baby is Rh-negative." This statement does not record understanding of the teaching. The purpose of Rho(D) immune globulin is to prevent sensitization of an Rh-negative mother to Rh-positive fetal blood. If the baby is Rh-negative, there is no need for Rho(D) immune globulin.
Choice B Reason:
"I will receive this medication when I am in labor." This statement does not record understanding of the teaching. Rho(D) immune globulin is typically given around 28 weeks of pregnancy and possibly after events that could lead to mixing of maternal and fetal blood, not specifically during labor.
Choice C Reason:
"I will need a second dose of this medication when my baby is 6 weeks old." This statement does not record understanding of the teaching. The administration of Rho(D) immune globulin is generally based on events during pregnancy and delivery, and a second dose is not typically given postpartum unless the baby is Rh-positive.
Choice D Reason:
"I will need this medication if I have an amniocentesis." This statement records understanding of the teaching. Rho(D) immune globulin is given to Rh-negative women during pregnancy and certain other situations to prevent the development of Rh incompatibility with a Rh-positive baby. If the mother undergoes procedures such as amniocentesis or experiences events that could lead to mixing of maternal and fetal blood, Rho(D) immune globulin is administered.
Correct Answer is C
Explanation
The correct answer is C. Place the client in a lateral position.
A. Elevating the client's legs is not the priority in this situation. Placing the client in a lateral position is more appropriate to improve blood flow and prevent supine hypotension.
B. Notifying the provider is an important action but not the immediate priority. Addressing the client's position and blood pressure is crucial before contacting the provider.
C. Placing the client in a lateral position is the priority nursing action.
The low blood pressure may be due to aortocaval compression (supine hypotension) caused by the weight of the uterus on the vena cava. Turning the client onto her side alleviates this compression and helps improve blood flow.
D. Monitoring vital signs every 5 minutes is important, but the immediate action should be to address the client's position and blood pressure. Continuous monitoring and further interventions can follow.
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