The nurse is caring for a client in labor. Which process will the nurse use to determine the duration of contractions?

Count the interval from the end of one contraction to the beginning of the next one

Count the interval from the beginning of one contraction to its end

Count the number of contractions that occur in 10 minutes

Count the interval between the acmes of two consecutive contractions

Answer and Explanation

The Correct Answer is B

A.   The interval from the end of one contraction to the beginning of the next one is the frequency, not the duration.
B.   Counting the interval from the beginning to the end of one contraction provides the duration of that contraction.
C.   Counting the number of contractions in 10 minutes gives the frequency, not the duration.

D. Counting the interval between the acmes (peaks) of two consecutive contractions is not a standard method for determining the duration of contractions. The duration is usually measured from the beginning to the end of a single contraction.

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Correct Answer is B

Explanation

A. Placing the client on her left side is important for optimizing fetal oxygenation but is not the first action when there is a report of a gush of fluid.
B. Notifying the registered nurse (RN) immediately is the first action to ensure prompt assessment and appropriate interventions for possible ruptured membranes.
C. Documenting the time and color of the fluid is important, but immediate notification of the RN takes precedence.
D. Checking fetal heart tones is important but should be done in conjunction with notifying the RN to assess the overall situation and determine the appropriate course of action.

A. FHR baseline 125 B. Temperature 99.9°F C. BP 142/90 D. Contractions lasting 45-60 seconds

Correct Answer is D

Explanation

A. A FHR baseline of 125 is within the normal range for a fetal heart rate.

B. A temperature of 99.9°F is a mild elevation and may not be an immediate concern.

C. Blood pressure of 142/90 may be elevated but may not require immediate action unless associated with other concerning symptoms.
D. Contractions lasting 45-60 seconds are prolonged and may lead to decreased fetal oxygenation. This finding should be reported immediately to the charge nurse.

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The nurse is caring for a client in labor. Which process will the nurse use to determine the duration of contractions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assisting a pregnant patient into bed after the patient reports a gush of fluid from the vagina. Which action will the nurse take first?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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