A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider?
Contraction resting period 35 seconds
Heart rate 100/min for a 10-min period
Four contractions in a 10-min period
Co Contraction lasting 85 seconds
The Correct Answer is D
The correct answer is Choice D: Contraction lasting 85 seconds.
Choice A rationale: A contraction resting period of 35 seconds is normal and expected during labor. The resting period allows the uterine muscle to relax and replenish its oxygen supply, which is essential for fetal well-being. The resting period also gives the client a chance to rest and cope with the pain of labor. A normal resting period ranges from 30 to 90 seconds, depending on the stage and phase of labor¹².
Choice B rationale: A heart rate of 100/min for a 10-min period is within the normal range for an adult. The normal resting heart rate for an adult is 60 to 100 beats per minute (bpm)³. During labor, the heart rate may increase due to factors such as pain, anxiety, dehydration, fever, or infection. However, a heart rate of 100/min is not considered a sign of distress or complication, unless it is accompanied by other symptoms such as chest pain, shortness of breath, or palpitations⁴⁵.
Choice C rationale: Four contractions in a 10-min period is a normal frequency for labor contractions. The frequency of contractions refers to how often they occur, measured from the beginning of one contraction to the beginning of the next. The normal frequency of contractions varies depending on the stage and phase of labor, but generally ranges from two to five contractions in 10 minutes¹².
Choice D rationale: A contraction lasting 85 seconds is too long and should be reported to the provider. The duration of contractions refers to how long they last, measured from the beginning to the end of one contraction. The normal duration of contractions ranges from 30 to 70 seconds, depending on the stage and phase of labor¹². A contraction lasting longer than 90 seconds is considered a prolonged contraction, which can reduce the blood flow and oxygen supply to the placenta and the fetus, leading to fetal hypoxia and acidosis. Prolonged contractions can also cause uterine rupture, placental abruption, or maternal hemorrhage .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A protruding abdomen is not specifically associated with being small for gestational age and can have various other causes in newborns.
Choice B rationale:
A gray umbilical cord is not a typical finding associated with being small for gestational age. Choice C rationale:
Moist skin is not a specific finding associated with being small for gestational age and can be observed in all newborns.
Choice D rationale:
Wide skull sutures are associated with being small for gestational age, as the skull bones may not fully close due to restricted growth in the womb.
Correct Answer is B
Explanation
The correct answer is Choice B, the nipple line.
Choice A rationale: The axillae, or underarms, are not used to measure chest circumference in a newborn. This area does not provide an accurate or consistent measurement of chest size due to the positioning and movement of the baby’s arms.
Choice B rationale: The nipple line is the correct anatomical landmark to use when measuring chest circumference in a newborn. This line is typically used because it provides a consistent and accurate measurement. It is located at the level of the nipples, which is approximately at the mid-chest level. This location allows for a measurement that is representative of the chest size, as it is at the broadest part of the chest.
Choice C rationale: The lower ribcage border is not the correct landmark for measuring chest circumference in a newborn. This area is too low and would not provide an accurate representation of the chest size. The measurement taken at this location would be smaller than the actual chest size, as it is below the broadest part of the chest.
Choice D rationale: The sternal notch is not an appropriate landmark for measuring chest circumference in a newborn. The sternal notch is located at the top of the sternum, near the base of the neck. A measurement taken at this location would not accurately represent the size of the chest, as it is above the broadest part of the chest.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.