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 A
Explanation
A. Late decelerations are associated with uteroplacental insufficiency, indicating that the baby is not getting enough oxygen during contractions.
B. Maternal hypotension can lead to decreased perfusion but is more likely associated with variable decelerations.
C. Cord compression is often associated with variable decelerations, not late decelerations.
D. Head compression typically does not cause late decelerations; it may be associated with early decelerations.
Correct Answer is ["A","B"]
Explanation
A. Effacement refers to the thinning of the cervix, making it easier for the cervix to dilate during labor.
B. Effacement also involves the shortening of the cervix, contributing to the progressive dilation during labor.
C. Engagement refers to the descent of the fetal head into the pelvic inlet, not a part of effacement.
D. Effacement does not involve the cervix becoming wider; dilation refers to the opening of the cervix.
E. Effacement does not involve the cervix becoming lower; descent of the presenting part is associated with engagement.
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