A nurse receives report about a client who is in labor and is having contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?

Contractions that last 45 seconds each with a 3 min rest between contractions

Contractions that last for 60 seconds each with a 3-min rest between contractions

Contractions that last for 60 seconds each with a 4-min rest between contractions

A contraction that lasts 4 min followed by a period of relaxation

Answer and Explanation

The Correct Answer is B

A. Contractions that last 45 seconds each with a 3-minute rest between contractions are less common. Typically, contractions last around 60 seconds during active labor.

B. Contractions that last for 60 seconds each with a 3-min rest between contractions is the expected pattern.

During active labor, contractions are commonly around 60 seconds in duration, and they occur approximately every 4-5 minutes.

C. Contractions that last for 60 seconds each with a 4-min rest between contractions are not consistent with the usual pattern of contractions in active labor. A 4-minute rest between contractions would be an extended interval.

D. A contraction that lasts for 4 minutes followed by a period of relaxation is not typical and may indicate a problem. Normal contractions usually last around 60 seconds or less.

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Correct Answer is C

Explanation

A. Helping the client to the bathroom to void is not the priority in this situation. The urge to push could indicate that the baby is descending, and the nurse should be prepared for imminent delivery.

B. Observing the perineum for signs of crowning is a valid action, but having the client pant during contractions is more appropriate at this stage. It can help prevent rapid descent and potential trauma if delivery is imminent.

C. Having the client pant during the next contractions is the correct action.

Panting during contractions may slow down the urge to push and prevent rapid delivery, especially if the healthcare provider is not present or the delivery is not imminent.

D. Assisting the client into a comfortable position is important, but the priority is to manage the urge to push. Panting can be an effective technique for delaying pushing until the healthcare provider is ready for the delivery.

A. "You can miss your period for several other reasons. Describe your typical menstrual cycle B. "If you have been sexually active and haven't used protection it is likely that you are pregnant C. "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet? D. "Because you have missed your period, you should try taking a home pregnancy test before you start worrying

Correct Answer is A

Explanation

Choice A Reason:

"You can miss your period for several other reasons. Describe your typical menstrual cycle." This response acknowledges that a missed period can result from various factors other than pregnancy, such as stress, changes in weight, hormonal fluctuations, or certain medical conditions. Understanding the client's typical menstrual cycle can help the nurse gather more information about potential reasons for the late period.

Choice B Reason:

"If you have been sexually active and haven't used protection, it is likely that you are pregnant. “This response assumes pregnancy without exploring other possibilities or the client's individual situation.

Choice C Reason:

"Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" While considering other signs of pregnancy is reasonable, focusing on abdominal enlargement may not be the most accurate early indicator, and it's essential to explore a broader range of symptoms.

Choice D Reason:

"Because you have missed your period, you should try taking a home pregnancy test before you start worrying. "While suggesting a home pregnancy test is reasonable, it may be more beneficial to gather additional information about the client's menstrual cycle and potential symptoms before jumping directly to a test.

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A nurse receives report about a client who is in labor and is having contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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