A nurse is assisting with the care of a client who is in the latent phase of labor and just had an amniotomy. Which of the following findings indicates that the fetus is at risk?
Recurrent variable deceleration of the FHR
Uterine contractions every 6 min
Uterine contractions lasting 30 to 45 seconds
Moderate variability of the FHR
The Correct Answer is A
A. Recurrent variable decelerations of the fetal heart rate (FHR) are concerning and can indicate fetal distress.
B. Uterine contractions every 6 minutes may not provide effective progress in labor, but it is not indicative of fetal distress.
C. Uterine contractions lasting 30 to 45 seconds are within the normal range for labor.
D. Moderate variability of the FHR is a reassuring sign and indicates that the fetus is tolerating labor well.
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Related Questions
Correct Answer is C
Explanation
A. A weight gain of 16.4 to 20.5 kg (36 to 45 lb) is excessive for a client with a pre-pregnancy BMI of 21, which falls within the normal range. Such weight gain is more appropriate for an underweight client.
B. A weight gain of 5 to 7.7 kg (11 to 17 lb) is inadequate for a client with a normal pre-pregnancy BMI. This range is suitable for an overweight or obese client.
C. A pre-pregnancy BMI of 21 falls within the normal range (18.5–24.9), and the recommended weight gain for clients in this category is 11.4 to 15.9 kg (25 to 35 lb). This range supports healthy fetal growth and reduces the risk of complications.
D. A weight gain of 8.2 to 10.9 kg (18 to 24 lb) is slightly below the recommended range for a client with a normal BMI and may not adequately support fetal development. This range is more appropriate for overweight individuals.
Correct Answer is A
Explanation
A. Left calf tenderness can be a sign of deep vein thrombosis (DVT), which is a serious postoperative complication and should be reported to the provider.
B. Moderate lochia rubra is an expected finding after a cesarean birth.
C. A urine output of 3,000 mL is within normal range and does not warrant immediate reporting to the provider.
D. Breast engorgement is an expected finding in the postpartum period, especially if the client is not breastfeeding. It does not require immediate reporting.
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