A charge nurse is teaching a group of staff nurses about fetal monitoring during labor.
Which of the following findings should the charge nurse instruct the staff members to report to the provider?
Absent early deceleration of fetal heart rate.
Fetal heart rate is 140/min.
Contraction frequency of 2 to 3 minutes apart.
Contraction durations of 95 to 100 seconds.
The Correct Answer is D
Choice A rationale
Absent early decelerations of the fetal heart rate are generally considered a reassuring sign. Early decelerations are a gradual decrease and return of the fetal heart rate associated with uterine contractions, thought to be caused by fetal head compression. Their absence does not typically warrant immediate reporting.
Choice B rationale
A fetal heart rate of 140 beats per minute falls within the normal range for a term fetus, which is typically between 110 and 160 beats per minute. This finding is reassuring and does not require immediate reporting to the provider.
Choice C rationale
Contraction frequency of 2 to 3 minutes apart indicates that the labor is progressing. While the overall pattern of contractions needs to be evaluated in conjunction with other factors like duration and intensity, a frequency within this range is not necessarily a concerning finding that requires immediate reporting on its own.
Choice D rationale
Contraction durations of 95 to 100 seconds are considered prolonged. Normal contraction duration in the active phase of labor typically ranges from 45 to 60 seconds. Prolonged contractions can reduce uterine blood flow and potentially lead to fetal hypoxia, making this a concerning finding that should be promptly reported to the provider for further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
This notation indicates three pregnancies (G3), one term birth (T1), two preterm births (P2), one abortion (A1), and three living children (L3). While the number of living children is correct, the total number of pregnancies is underestimated by excluding the current pregnancy.
Choice B rationale
This notation accurately reflects four pregnancies (G4: the elective abortion, the daughter, the twins, and the current pregnancy), one term birth (T1: the daughter born at 40 weeks), two preterm births (P2: the twin boys born at 34 weeks), one abortion (A1: the elective abortion), and three living children (L3: the daughter and the twin boys).
Choice C rationale
This notation indicates three pregnancies (G3), one term birth (T1), one preterm birth (P1), one abortion (A1), and three living children (L3). The number of preterm births is incorrect, as there were two preterm births (the twins).
Choice D rationale
This notation indicates four pregnancies (G4), one term birth (T1), one preterm birth (P1), one abortion (A1), and three living children (L3). The number of preterm births is incorrect, as there were two preterm births (the twins).
Correct Answer is A
Explanation
Choice A rationale
The 1-hour glucose tolerance test is typically performed between 24 and 28 weeks of gestation to screen for gestational diabetes. This screening involves measuring the client's blood glucose level one hour after consuming a 50-gram glucose load. A normal result is generally considered to be a blood glucose level below 130-140 mg/dL.
Choice B rationale
Rubella titer is usually assessed early in pregnancy, ideally during the first prenatal visit, to determine the woman's immunity to rubella. If the woman is not immune, vaccination is typically offered postpartum to prevent infection in subsequent pregnancies, as rubella infection during pregnancy can cause serious congenital defects.
Choice C rationale
Sexually transmitted disease testing is ideally conducted at the initial prenatal visit to identify and treat any infections early in pregnancy, reducing the risk of transmission to the fetus and other complications. While repeat testing may be indicated based on risk factors, it is not a routine test specifically scheduled for the 24-week appointment for all clients.
Choice D rationale
Group B Streptococcus (GBS) culture is typically performed later in pregnancy, usually between 35 and 37 weeks of gestation, to determine if the woman is colonized with GBS. This is important for intrapartum management to prevent neonatal GBS infection.
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