A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider?
Contractions occurring every 3 to 5 min
Each contraction lasting longer than 110 seconds
Contractions are strong in intensity
Client reports feeling contractions in lower back
The Correct Answer is B
Choice A reason: Contractions occurring every 3 to 5 min are normal and expected in the active phase of the first stage of labor, which lasts from 4 to 8 cm of cervical dilation. The nurse does not need to report this finding to the provider.
Choice B reason: Each contraction lasting longer than 110 seconds is abnormal and concerning, as it can indicate uterine hyperstimulation, which can reduce the blood flow to the placenta and fetus, and cause fetal distress. The nurse should report this finding to the provider immediately and prepare for interventions, such as stopping oxytocin infusion, administering tocolytics, or performing an emergency cesarean section.
Choice C reason: Contractions are strong in intensity are also normal and expected in the active phase of the first stage of labor, as they facilitate the cervical dilation and effacement. The nurse does not need to report this finding to the provider.
Choice D reason: Client reports feeling contractions in lower back are common and not harmful, especially if the fetus is in the occiput posterior position, which causes the fetal head to press against the sacrum. The nurse does not need to report this finding to the provider, but can offer comfort measures, such as massage, counterpressure, heat, or position changes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. No special treatment is necessary.
Choice A reason: Prone positioning is not typically recommended for a fractured clavicle in infants. It does not facilitate bone alignment in the case of clavicle fractures and is not part of standard care.
Choice B reason: This is the correct choice because clavicle fractures in newborns generally heal on their own without the need for special treatment. Parents may be instructed to pin the child’s sleeve to the front of their clothing to avoid moving the arm while it heals, but beyond gentle handling, no other special treatment is necessary. In most cases, clavicle fractures in newborns heal very quickly without any problems, and usually, no treatment is required.
Choice C reason: Immobilization and casting are not standard care for newborn clavicle fractures. These fractures typically heal without such interventions, and immobilization with a cast is not needed for these types of injuries in infants.
Choice D reason: While range-of-motion exercises might be beneficial later in the healing process, they are not the primary consideration immediately after the fracture occurs. The initial care plan focuses on gentle handling and comfort for the infant, not on exercises.
Correct Answer is D
Explanation
Choice A reason: "I'll basically follow the same diet that I was following before I became pregnant." is an incorrect statement, because it indicates that the client does not understand the need for dietary changes during pregnancy. The client should follow a diet that is individualized, balanced, and consistent in carbohydrate intake, and that meets the nutritional needs of pregnancy.
Choice B reason: "Because I need extra protein, I'll have to increase my intake of milk and meat." is an incorrect statement, because it indicates that the client does not understand the role of protein in diabetes management. The client should consume adequate but not excessive amounts of protein, and choose lean sources of protein, such as poultry, fish, eggs, and legumes.
Choice C reason: "I'll adjust my diet and insulin based on the results of my urine tests for glucose." is an incorrect statement, because it indicates that the client does not understand the limitations of urine tests for glucose. The client should monitor her blood glucose levels regularly, and adjust her diet and insulin accordingly, under the guidance of the provider. Urine tests for glucose are not accurate or reliable indicators of blood glucose levels.
Choice D reason: "Pregnancy affects insulin production, so I'll need to make adjustments in my diet." is a correct statement, because it indicates that the client understands the impact of pregnancy on diabetes. The client should be aware that pregnancy can cause insulin resistance, especially in the second and third trimesters, and that her diet may need to be modified to achieve optimal glycemic control.
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