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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?

A.

Absent early deceleration of fetal heart rate.

B.

Fetal heart rate is 140/min.

C.

Contraction frequency of 2 to 3 minutes apart.

D.

Contraction durations of 95 to 100 seconds.

Answer and Explanation

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.


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Related Questions

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

Rationales for Each Condition

Molar Pregnancy

  1. Abdominal Pain: In a molar pregnancy, the uterus enlarges disproportionately due to abnormal trophoblastic growth. This excessive expansion can cause discomfort or mild cramping.
  2. Blood Pressure: Molar pregnancies can be associated with gestational trophoblastic disease, which may lead to preeclampsia-like symptoms. However, this client’s blood pressure is currently within normal limits (120/78 mm Hg), so severe hypertension has not yet developed.
  3. Ultrasound Findings: The presence of grape-like vesicles within the uterus and the absence of a fetal heartbeat are hallmark findings of a molar pregnancy, indicating abnormal placental tissue proliferation.
  4. Perineal Pad Findings: The passage of small clear vesicles is a characteristic feature of a molar pregnancy, distinguishing it from other causes of vaginal bleeding in pregnancy.

Ectopic Pregnancy

  1. Abdominal Pain: Ectopic pregnancies often cause sharp lower abdominal pain due to tubal rupture or irritation. However, in this case, the client’s pain is mild and less suggestive of tubal rupture.
  2. Blood Pressure: If an ectopic pregnancy ruptures, hypotension due to internal bleeding would be expected. Since the client’s blood pressure is normal, this finding does not support an ectopic pregnancy.
  3. Ultrasound Findings: The absence of a fetal heartbeat and vesicular structures inside the uterus make ectopic pregnancy unlikely, as ectopic pregnancies typically occur in the fallopian tube.
  4. Perineal Pad Findings: Ectopic pregnancies rarely cause the passage of vesicular tissue, further suggesting that this is not an ectopic pregnancy.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

The nurse should anticipate a provider prescription for pyridoxine due to the client’s severe dehydration.

Rationale for correct answers

Pyridoxine (vitamin B6) is recommended for nausea and vomiting in pregnancy (NVP), commonly known as hyperemesis gravidarum (HG), especially in patients with persistent symptoms leading to dehydration. Severe dehydration is confirmed by elevated urine specific gravity (normal: 1.002–1.030), low sodium (normal: 135–145 mEq/L), and positive ketones, indicating excessive vomiting and malnutrition.

Rationale for incorrect Response 1 options

  • Antibiotics: There is no evidence of infection; urinalysis and WBC count are within normal limits.
  • Magnesium sulfate: Used for eclampsia or preterm labor prevention, not for HG.
  • Oxytocin: Stimulates uterine contractions and is contraindicated during early pregnancy unless labor induction is required.

Rationale for incorrect Response 2 options

  • Urinary tract infection: No leukocytes or nitrites in urine, and WBC count is normal (4,500–11,000/mm³).
  • Preeclampsia: No proteinuria or hypertension (≥140/90 mm Hg).
  • Preterm labor: No uterine contractions or cervical changes.

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