A nurse is assisting with the cane of a labor and delivery unit
The nurse is contacting the provider regarding the client's status. Which of the following findings should the nurse include in the report?
Select the 4 findings that the nurse should report
Gestational age
Vaginal examination
Uterine contractions
Maternal blood pressure
Correct Answer : A,C,E,F
A. Gestational age: The client is 31 weeks of gestation, which is preterm. This is critical information to determine the risk for preterm labor and guide interventions such as corticosteroid administration for fetal lung maturity or tocolytic therapy.
B. Vaginal examination: While a vaginal examination can provide information on cervical dilation and effacement, it is not appropriate to perform without consulting the provider first, especially in a preterm client with contractions.
C. Uterine contractions: The frequency (every 10 minutes) and duration (lasting 30 seconds) of contractions are critical findings that suggest the possibility of preterm labor. This information helps the provider decide on appropriate diagnostic or therapeutic measures, such as starting a tocolytic or performing fetal monitoring.
D. Maternal blood pressure: The maternal blood pressure is within normal limits (118/78 mmHg) and does not indicate a pressing concern in this scenario.
E. Maternal report of pain: The client reports cramping and low back pain, which could indicate preterm labor or another issue affecting uterine activity. This subjective information helps the provider assess the need for further evaluation or pain relief measures.
F. Fetal heart rate: The FHR is 140 beats per minute, which is within the normal range (110-160 bpm). A normal FHR suggests that the fetus is not in distress, but continuous monitoring and assessment are necessary to ensure the fetus remains well-oxygenated, especially in the context of uterine contractions.
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Related Questions
Correct Answer is C
Explanation
A. Caput succedaneum: This swelling crosses suture lines and involves edema caused by birth trauma.
B. Molding: This refers to the shaping of the fetal head to pass through the birth canal and does not involve swelling.
C. Cephalohematoma: A localized collection of blood between the skull and periosteum, which does not cross suture lines, is characteristic of cephalohematoma.
D. Nevus flammeus: This is a flat, red birthmark (port-wine stain) and is unrelated to swelling or trauma.
Correct Answer is A
Explanation
A. Assure the client that the score is within the expected range: A score of 8–10 on a biophysical profile indicates fetal well-being, requiring no intervention.
B. Offer the client orange juice and repeat the assessment in 1 hour: This is unnecessary since the score indicates no concern.
C. Administer oxygen and notify the provider: There is no indication of fetal distress.
D. Assist the client into a side-lying position: A position change is not needed as there is no evidence of compromise.
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