For a woman at 42 weeks gestation, which finding would require more assessment by the nurse?

Fetal heart rate of 118 beats/min

One fetal movement noted in a two-hour assessment by the mother

Cervix dilated 2 cm and 50% effaced

Score of 8 on the biophysical profile

Answer and Explanation

The Correct Answer is B

A. Fetal heart rate of 118 beats/min. A fetal heart rate of 118 bpm is within the normal range of 110-160 bpm and does not necessarily indicate fetal distress. While continuous monitoring is important in post-term pregnancies, this finding alone does not require urgent assessment.

B. One fetal movement noted in a two-hour assessment by the mother. Decreased fetal movement is a concerning sign that requires further assessment. At 42 weeks gestation, the aging placenta may lead to reduced oxygen and nutrient supply, increasing the risk of fetal compromise. Normally, at least 10 movements should be felt within two hours. A significant decrease in movement could indicate fetal distress or hypoxia, requiring immediate evaluation with a non-stress test (NST) or biophysical profile (BPP).

C. Cervix dilated 2 cm and 50% effaced. A partially dilated and effaced cervix is expected in a post-term pregnancy and does not indicate fetal distress. It suggests that labor may be approaching but does not require additional urgent assessment.

D. Score of 8 on the biophysical profile. A biophysical profile (BPP) score of 8 out of 10 is reassuring and indicates normal fetal well-being. If the score were 4 or lower, it would require immediate intervention, but a score of 8 suggests adequate oxygenation and fetal health.

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Correct Answer is A

Explanation

A. The cervix is effacing and dilated to 2 cm. Cervical changes, including effacement and dilation, are the most definitive signs of preterm labor. Uterine contractions alone do not confirm preterm labor unless they result in cervical dilation, indicating that labor is progressing.

B. Irregular, mild uterine contractions are occurring every 15-30 minutes. Irregular contractions, known as Braxton Hicks contractions, can be common in pregnancy and do not necessarily indicate preterm labor. True preterm labor involves regular contractions that lead to cervical changes.

C. Estriol is not found in maternal saliva. The absence of estriol in maternal saliva does not confirm or rule out preterm labor. Salivary estriol testing is not a widely used or reliable diagnostic tool for determining the onset of preterm labor.

D. Fetal fibronectin is present in vaginal secretion. Fetal fibronectin (fFN) is a protein found in vaginal secretions between 22-34 weeks of pregnancy and can indicate a risk of preterm labor, but its presence alone does not confirm that labor is actively occurring. A positive fFN test means the patient may be at increased risk for preterm labor, but cervical changes remain the best indicator of actual labor.

A. The type of uterine incision used for the cesarean. B. The client's blood type and Rh status. C. The client's response to anesthesia used for the last delivery. D. Lab values, especially hemoglobin and hematocrit

Correct Answer is A

Explanation

A. The type of uterine incision used for the cesarean. This is the most important information because the type of uterine incision determines whether a trial of labor after cesarean (TOLAC) is safe. A low transverse incision is the safest and has the lowest risk of uterine rupture, while a classical (vertical) incision carries a high risk of rupture and contraindicates vaginal birth after cesarean (VBAC).

B. The client's blood type and Rh status. While blood type and Rh status are important for managing potential complications such as Rh incompatibility, they do not determine the safety of a VBAC attempt. The uterine incision type is the key factor in assessing the risk of uterine rupture.

C. The client's response to anesthesia used for the last delivery. Although anesthesia history is relevant for planning pain management, it is not the most critical factor in determining whether the patient can safely attempt a vaginal delivery after a prior cesarean.

D. Lab values, especially hemoglobin and hematocrit. Hemoglobin and hematocrit levels help assess for anemia or blood loss risk, but they do not affect the safety of a VBAC attempt. The primary concern is uterine integrity, which is determined by the type of previous cesarean incision.

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For a woman at 42 weeks gestation, which finding would require more assessment by the nurse?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is A

Explanation

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