A nurse is monitoring a client who is in the active phase of labor and has an electronic fetal monitor.
Which of the following findings should the nurse expect?
Uterine contractions every 15 minutes.
FHR baseline 166/min with minimal variability.
Late decelerations in FHR.
Contraction duration of 75 seconds.
The Correct Answer is D
Choice A rationale
Uterine contractions every 15 minutes are characteristic of the latent phase of labor, not the active phase. In the active phase, contractions typically become stronger, more frequent, and more regular, occurring every 2 to 5 minutes, signifying progressive cervical dilation.
Choice B rationale
A fetal heart rate (FHR) baseline of 166/min with minimal variability is concerning. While a baseline up to 160/min is generally normal, 166/min is slightly elevated, and minimal variability (5 bpm or less) can indicate fetal hypoxia or acidosis, necessitating further assessment and intervention. Normal FHR baseline is 110-160 bpm.
Choice C rationale
Late decelerations in FHR are non-reassuring findings indicative of uteroplacental insufficiency, meaning inadequate oxygen transfer to the fetus. These decelerations suggest potential fetal distress and require immediate intervention and reporting to the provider, not an expected finding in active labor.
Choice D rationale
Contraction duration of 75 seconds is an expected finding in the active phase of labor. During this phase, contractions typically last 45 to 90 seconds. This duration contributes to effective cervical effacement and dilation, signifying adequate uterine activity for labor progression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
The nurse should identify that weeks of gestation and contraction pattern are findings that require follow-up.
Rationale for correct answers:
Weeks of gestation at 32 weeks indicate a preterm pregnancy (<37 weeks), making any contractions concerning for possible preterm labor. The contraction pattern of increasing frequency (from every 5 minutes to every 3 minutes), longer duration (30 to 60 seconds), and moderate intensity signifies active uterine activity that can precipitate cervical changes and preterm birth risk. These two parameters warrant close monitoring and intervention to prevent premature delivery.
Rationale for incorrect answers (Response 1 options):
Blood pressure is within normal limits (128/83 and 117/80 mm Hg), so hypertensive disorders like preeclampsia are not indicated here. Pain score remains low (2/10), which is mild and not a primary indicator for urgent intervention. Parity (G1P0) does not influence immediate risk assessment for this clinical presentation.
Rationale for incorrect answers (Response 2 options):
Fetal heart rate remains normal at 140/min with no decelerations, indicating fetal well-being at this time. Nitrazine test is negative, showing intact membranes, which reduces the risk of premature rupture of membranes. Temperature is normal at 37°C, ruling out infection as a cause of contractions. Therefore, these findings do not require urgent follow-up in this scenario.
Correct Answer is A
Explanation
Choice A rationale
For clients prescribed methadone during pregnancy, breastfeeding is generally encouraged due to the benefits of breast milk for the infant. Methadone excretion into breast milk is minimal and not considered harmful, and it can help to reduce the severity of neonatal abstinence syndrome.
Choice B rationale
Methamphetamine use during pregnancy is associated with several adverse fetal outcomes, but fetal macrosomia (abnormally large baby) is not typically one of them. Instead, it is more commonly linked to intrauterine growth restriction, preterm birth, and small for gestational age infants due to vasoconstrictive effects.
Choice C rationale
For newborns experiencing neonatal abstinence syndrome due to prenatal substance exposure, environmental stimuli should be decreased, not increased. Reducing stimuli like bright lights, loud noises, and excessive handling helps to minimize agitation, irritability, and seizures in these vulnerable infants.
Choice D rationale
Increased head circumference is not an expected finding in a newborn with fetal alcohol syndrome (FAS). In fact, microcephaly (abnormally small head circumference) is a characteristic diagnostic criterion for FAS, reflecting the detrimental effects of alcohol on fetal brain development.
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.