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 lasting 85 seconds
Contraction resting period 35 seconds
Heart rate 100/min for a 10-min period
One contraction in a 10-min period
The Correct Answer is A
Choice A rationale:
Contraction duration: Contractions that last longer than 75 seconds are considered abnormal and should be reported to the
provider. This is because prolonged contractions can decrease oxygen supply to the fetus, leading to fetal distress.
Risk of uterine rupture: Excessively long contractions can also increase the risk of uterine rupture, a serious complication that
can endanger both the mother and the fetus.
Signs of fetal distress: The nurse should closely monitor the fetal heart rate for any signs of distress, such as late decelerations,
decreased variability, or bradycardia.
Need for intervention: If the contractions remain prolonged or if fetal distress is detected, the provider may need to intervene
to ensure the safety of both the mother and the fetus. This could involve measures such as administering medications to stop
or slow down labor, or performing a cesarean delivery.
Choice B rationale:
Contraction resting period: A contraction resting period of 35 seconds is within the normal range. Ideally, the resting period
between contractions should be at least 60 seconds, but it can vary. However, a resting period shorter than 30 seconds could
be a sign of tachysystole (excessively frequent contractions), which may also require intervention.
Choice C rationale:
Maternal heart rate: A maternal heart rate of 100 beats per minute is considered normal during labor. Heart rate can increase
with exertion, pain, and anxiety, which are common during labor. However, it's important to monitor for significant
tachycardia (heart rate over 120 beats per minute), which could indicate underlying issues such as dehydration or infection.
Choice D rationale:
Contraction frequency: One contraction in a 10-minute period is not indicative of active labor. Labor is typically defined as
having regular contractions that are 5 minutes apart or less, lasting for 45-60 seconds each, and causing progressive cervical
change. In early labor, contractions may be more sporadic and less intense.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
During the taking-in phase, which typically lasts 2-3 days postpartum, the client's primary focus is on herself and her own
needs. She may be physically exhausted and emotionally overwhelmed by the birthing experience.
Interest in learning about newborn care is more characteristic of the taking-hold phase, which begins around the third day
postpartum.
Choice B rationale:
Concerns about managing at home are more likely to arise during the letting-go phase, which begins around the fourth week
postpartum.
During this phase, the mother is adjusting to her new role and responsibilities, and she may feel anxious about her ability to
care for her baby on her own.
Choice C rationale:
While some mothers may be eager to share their birth stories during the taking-in phase, it is not a universal characteristic of
this phase.
Many mothers are still processing their experiences and may not be ready to talk about them in detail.
Choice D rationale:
The focus on personal needs and recovery is a hallmark of the taking-in phase.
The mother is typically preoccupied with physical comfort, rest, and nourishment.
She may also be emotionally labile, experiencing a range of emotions from euphoria to sadness.
Correct Answer is C
Explanation
Choice C rationale:
Endometritis is an inflammation of the inner lining of the uterus (endometrium). It is a common complication after childbirth,
affecting up to 1 in 10 women who deliver vaginally. Symptoms of endometritis typically develop within 1-3 days after
childbirth, but they can sometimes take up to a week to appear.
Swelling in the ankles is a common symptom of endometritis. This is because endometritis can cause inflammation and fluid
buildup in the pelvis, which can put pressure on the veins in the legs and cause them to swell.
Choice A rationale:
An increased heart rate can be a symptom of endometritis, but it is not a specific symptom. An increased heart rate can also be
caused by many other factors, such as fever, dehydration, and anxiety.
Choice B rationale:
Decreased appetite can be a symptom of endometritis, but it is not a specific symptom. Decreased appetite can also be caused
by many other factors, such as pain, fatigue, and nausea.
Choice D rationale:
Dry skin is not a typical symptom of endometritis. Dry skin can be caused by many other factors, such as dehydration,
medications, and underlying medical conditions.
Therefore, the most likely manifestation of endometritis in this patient is swelling in the ankles.
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