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. Artificial rupture of membranes involves breaking the amniotic sac to induce or augment labor but is not a method for cervical ripening.
B. Laminaria is a common mechanical method used to ripen the cervix before labor induction.
Laminaria tents are placed in the cervix to gradually dilate and soften it.
C. A catheter filled with sterile saline may be used for cervical ripening, but it is not the most common mechanical method.
D. Membrane stripping involves separating the amniotic membrane from the cervix, not a mechanical method for cervical ripening.
Correct Answer is C
Explanation
A. While shape and height are important aspects, tone is also a key component in assessing the fundus after childbirth.
B. Position is part of the assessment, but the shape and tone are equally crucial components.
C. This choice correctly includes all the essential aspects of a fundal assessment: tone, shape, and position.
D. While shape and height are important, tone and position are equally vital components in assessing the fundus.
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