A nurse is assisting in the care of a client who is in the second stage of labor.
Which of the following findings should the nurse report to the provider?
Bloody show from the vagina
Early decelerations in the FHR
Uterine contraction lasting 2 minutes
Pelvic pressure with contractions
The Correct Answer is C
Choice A rationale:
The presence of a “bloody show” from the vagina is a normal part of labor. It’s caused by the expulsion of the mucus plug that
has sealed the cervix during pregnancy. This is a common occurrence and does not need to be reported to the provider.
Choice B rationale:
Early decelerations in the Fetal Heart Rate (FHR) are usually not a cause for concern. They are often a sign of head
compression, which is a normal occurrence during labor. Therefore, this finding does not need to be reported to the provider.
Choice C rationale:
Uterine contractions lasting 2 minutes could be a sign of a complication known as “uterine tachysystole” or “hyperstimulation”. This condition can reduce oxygen supply to the baby and may require medical intervention. Therefore, this finding should be reported to the provider.
Choice D rationale:
Feeling pelvic pressure with contractions is a normal part of the second stage of labor. This pressure is due to the baby moving
down into the birth canal. Therefore, this finding does not need to be reported to the provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Pushing continuously throughout the entire contraction can lead to maternal exhaustion and may not be the most effective way to progress labor. It’s important for the mother to conserve her energy and work with her body’s natural rhythms.
Choice B rationale:
Taking a deep, cleansing breath before and after each contraction can help the mother manage pain and keep her energy up.
This technique is often recommended because it allows the mother to rest briefly and gather strength for the next contraction.
Choice C rationale:
While it’s important for the nurse to monitor contractions and provide guidance, the urge to push is a natural response that
can vary among individuals. Telling the mother when to push according to contractions may not align with her body’s natural
instincts.
Choice D rationale:
Holding one’s breath and pushing while someone counts to ten is an outdated practice. This method can cause unnecessary
strain and doesn’t take into account the individual rhythms and responses of the mother’s body.
Correct Answer is A
Explanation
Choice A rationale:
Heavy vaginal bleeding in late pregnancy, especially at 39 weeks of gestation, is a medical emergency that requires immediate
intervention.
It can be a sign of placental abruption, a serious condition in which the placenta separates from the uterine wall prematurely.
Placental abruption can lead to fetal distress and maternal hemorrhage, both of which can be life-threatening.
Cesarean birth is the quickest and safest way to deliver the baby in this situation.
It allows the healthcare team to control the bleeding and prevent further complications.
Delaying a cesarean birth can put the mother and baby at increased risk.
Choice B rationale:
Antibiotics are not indicated for heavy vaginal bleeding in late pregnancy.
They are used to treat infections, not bleeding.
There is no evidence to suggest that the client has an infection.
Choice C rationale:
Magnesium sulfate is a medication used to prevent seizures in women with preeclampsia.
It is not indicated for heavy vaginal bleeding.
There is no evidence to suggest that the client has preeclampsia.
Choice D rationale:
A cervical examination is not necessary in this situation.
The priority is to deliver the baby as quickly as possible.
A cervical examination would only delay the delivery.
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