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 B
Explanation
Choice A rationale
During labor, the body experiences physiological stress and an inflammatory response, leading to an increase in white blood cell count. This leukocytosis is a normal physiological adaptation to the physical demands of labor and tissue remodeling, not a decrease. A normal WBC count is typically 4,500-11,000 cells/µL, and it can rise to 15,000-20,000 cells/µL during labor.
Choice B rationale
Labor is an energy-intensive process that increases metabolic demands, leading to greater glucose utilization by uterine muscles and other tissues. This increased consumption of glucose can result in a decrease in blood glucose levels as the body expends energy to fuel contractions and other physiological activities. A normal blood glucose range is 70-100 mg/dL.
Choice C rationale
The pain and physiological stress of labor typically cause an increase in respiratory rate, not a decrease. The body tries to compensate for the increased metabolic demand and oxygen consumption by increasing ventilation. A decrease in respiratory rate would be an unexpected and potentially concerning finding, indicating respiratory depression. A normal respiratory rate is 12-20 breaths per minute.
Choice D rationale
While slight fluctuations can occur, a significant decrease in temperature is not an expected finding during labor. The metabolic activity and physical exertion of labor can slightly elevate body temperature, or it may remain stable. A decrease in temperature could indicate hypothermia or a systemic issue, which is not a normal physiological response to labor. A normal temperature is 36.5-37.5°C.
Correct Answer is ["A","E"]
Explanation
Choice A rationale
Fetal heart rate assessment is paramount before administering an opioid analgesic during labor. Opioids can cross the placental barrier and cause central nervous system depression in the fetus, potentially leading to decreased fetal heart rate variability or transient decelerations. Therefore, a baseline and ongoing fetal heart rate monitoring is essential to ensure fetal well-being.
Choice B rationale
Deep tendon reflexes are primarily assessed when administering magnesium sulfate for preeclampsia, not typically before opioid analgesics. Magnesium sulfate can cause central nervous system depression and affect neuromuscular transmission, necessitating regular monitoring of deep tendon reflexes to assess for signs of toxicity. Opioids do not directly affect reflex activity in the same manner.
Choice C rationale
Blood glucose levels are not a standard assessment before administering opioid analgesics during labor. Blood glucose monitoring is crucial for clients with diabetes or gestational diabetes, or those receiving intravenous dextrose, but it is not directly related to opioid administration and its immediate effects on the mother or fetus.
Choice D rationale
Blood pressure assessment is crucial before administering an opioid analgesic because these medications can cause maternal hypotension due to their vasodilatory effects. Hypotension can reduce placental perfusion, compromising fetal oxygenation. Establishing a baseline blood pressure and monitoring it closely after administration helps ensure maternal cardiovascular stability and fetal well-being.
Choice E rationale
Pain level assessment is fundamental before administering an opioid analgesic. The primary purpose of administering an opioid is to alleviate labor pain. A thorough assessment of the intensity, location, and character of pain guides the choice, dosage, and timing of the analgesic, ensuring effective pain management and patient comfort while minimizing unnecessary medication.
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.