The nurse is caring for a client in labor. Which assessment finding will the nurse report to the charge nurse immediately?
FHR baseline 125
Temperature 99.9°F
BP 142/90
Contractions lasting 45-60 seconds
The Correct Answer is D
A. A FHR baseline of 125 is within the normal range for a fetal heart rate.
B. A temperature of 99.9°F is a mild elevation and may not be an immediate concern.
C. Blood pressure of 142/90 may be elevated but may not require immediate action unless associated with other concerning symptoms.
D. Contractions lasting 45-60 seconds are prolonged and may lead to decreased fetal oxygenation. This finding should be reported immediately to the charge nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The interval from the end of one contraction to the beginning of the next one is the frequency, not the duration.
B. Counting the interval from the beginning to the end of one contraction provides the duration of that contraction.
C. Counting the number of contractions in 10 minutes gives the frequency, not the duration.
D. Counting the interval between the acmes (peaks) of two consecutive contractions is not a standard method for determining the duration of contractions. The duration is usually measured from the beginning to the end of a single contraction.
Correct Answer is B
Explanation
A. Late decelerations typically start after the contraction has reached its peak and return to baseline after the contraction ends, not during the contraction.
B. Early decelerations coincide with the contraction and return to baseline by the end of the contraction. They are typically considered benign and related to head compression.
C. Accelerations are brief increases in the FHR above the baseline and are usually associated with fetal movement.
D. Variable decelerations are abrupt decreases in the FHR, often unrelated to contractions, and have an erratic pattern.
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