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A nurse is assessing a woman in labor.
Which finding would the nurse identify as a cause for concern during a contraction?.

Blood pressure rise from 110/60 mm Hg to 120/74.

White blood cell count of 12,000 cells/mm.

Respiratory rate of 10 breaths/minute.

Heart rate increase from 76 bpm to 90 bpm.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A slight increase in blood pressure during contractions is normal.

Choice B rationale:

A white blood cell count of 12,000 cells/mm is within the normal range.

Choice C rationale:

A respiratory rate of 10 breaths/minute is low and could indicate respiratory depression.

Choice D rationale:

A heart rate increase from 76 bpm to 90 bpm is within the normal range.

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Correct Answer is C

Explanation

Choice A rationale:

Transient fetal hypoxia is not typically associated with cloudy amniotic fluid. It’s a condition where the fetus doesn’t get enough oxygen.

Choice B rationale:

Normal amniotic fluid is clear or light yellow. Cloudy amniotic fluid is not considered normal.

Choice C rationale:

Cloudy amniotic fluid could indicate a possible infection. The cloudiness can be due to the presence of bacteria and inflammatory cells.

Choice D rationale:

Meconium passage can cause the amniotic fluid to become green or brown, not typically cloudy. So, the correct answer for both questions 26 and 27 is C.

A. Notify the primary care provider immediately. B. Perform a vaginal exam. C. Change the linen saver pad. D. Check the fetal heart rate.

Correct Answer is D

Explanation

Choice A rationale:

Notifying the primary care provider is important but not the immediate next step. The nurse has other immediate responsibilities to ensure the safety of the mother and baby.

Choice B rationale:

A vaginal exam could introduce bacteria into the uterus and is not the immediate next step after rupture of membranes.

Choice C rationale:

Changing the linen saver pad is not the immediate next step. While it might be necessary for the comfort of the mother, it does not address the potential risks associated with rupture of membranes.

Choice D rationale:

Checking the fetal heart rate is the correct next step. This ensures that the baby is not in distress following the rupture of membranes.

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A nurse is assessing a woman in labor. Which finding would the nurse identify as a cause for concern during a contraction?.

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Naxlex Comprehensive Predictor Exams

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as:.

Correct Answer is C

Explanation

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next?

Correct Answer is D

Explanation

A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage?

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A nurse is assessing a woman in labor.
Which finding would the nurse identify as a cause for concern during a contraction?.