The nurse is contacting the provider regarding the client's status during active labor. Which of the following findings should the nurse report to the provider? Select the findings the nurse should report:
Gestational age is 39 weeks and 2 days.
Vaginal examination reveals cervix dilated to 8 cm, 100% effaced, and fetal station +1.
Uterine contractions occurring every 2 minutes, lasting 90 seconds, with strong intensity.
Blood pressure is 162/108 mmHg.
Birthing parent reports pain rated 7 out of 10.
Fetal heart rate is 170 beats per minute with minimal variability.
Correct Answer : A,B,C,D
The correct answer is Choice D, Choice F
Choice A rationale: Gestational age of 39 weeks and 2 days falls within the normal term range, which spans from 37 weeks to 41 weeks and 6 days. At this stage, fetal lung maturity is typically achieved, and labor is considered appropriate. There is no pathological implication associated with this gestational age, and it does not warrant provider notification unless accompanied by abnormal findings. Therefore, this parameter is physiologically expected and not concerning in isolation.
Choice B rationale: Cervical dilation of 8 cm with 100% effacement and fetal station +1 indicates the transition phase of labor, which is a normal progression during active labor. Station +1 means the fetal presenting part is descending into the birth canal, and full effacement reflects readiness for delivery. These findings are expected and do not represent a deviation from normal labor physiology. No pathological signs are present, so provider notification is not immediately required.
Choice C rationale: Contractions every 2 minutes lasting 90 seconds with strong intensity are common during the late active or transition phase of labor. This pattern reflects adequate uterine activity for cervical change and fetal descent. While frequent, this contraction pattern is not abnormal unless accompanied by signs of fetal distress or uterine hyperstimulation. In isolation, it does not necessitate provider contact unless additional concerning signs are present.
Choice D rationale: A blood pressure of 162/108 mmHg exceeds the diagnostic threshold for severe hypertension in pregnancy, which is ≥160 systolic or ≥110 diastolic. This level raises concern for preeclampsia or eclampsia, especially if accompanied by proteinuria, headache, or visual disturbances. Normal pregnancy blood pressure should remain below 140/90 mmHg. Immediate provider notification is warranted due to risk of maternal and fetal complications including placental abruption and stroke.
Choice E rationale: A pain rating of 7 out of 10 during active labor is expected and reflects the intensity of uterine contractions and cervical dilation. Pain perception varies, but this level is not considered abnormal or indicative of pathology. Pain management should be addressed per patient preference, but it does not require urgent provider notification unless pain is unrelieved or associated with other concerning symptoms.
Choice F rationale: A fetal heart rate of 170 beats per minute exceeds the normal range of 110 to 160 bpm and is classified as fetal tachycardia. Minimal variability further suggests compromised autonomic regulation, possibly due to hypoxia, infection, or maternal fever. Variability is a key indicator of fetal well-being, and minimal variability (<5 bpm) is concerning. These findings warrant immediate provider notification to assess fetal status and intervene if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Administering oxytocin is not appropriate at this stage since the fetal head at a +5 station indicates imminent delivery.
Choice B rationale
Applying fundal pressure is not recommended and can cause complications such as uterine rupture or maternal injury.
Choice C rationale
Suctioning the mouth of the infant at the perineum should be done only after the head is delivered to clear airway obstructions.
Choice D rationale
Observing for the presence of a nuchal cord is crucial as it can cause complications during delivery, requiring immediate attention.
Correct Answer is ["B","D","F"]
Explanation
Choice A rationale
Documenting the findings in the client's medical record is important but is not the priority action when persistent late decelerations are noted. Immediate interventions are needed to improve fetal oxygenation.
Choice B rationale
Notifying the healthcare provider immediately is crucial as persistent late decelerations indicate fetal distress. The provider can decide on further interventions to ensure the safety of the mother and fetus.
Choice C rationale
Administering a tocolytic medication to stop contractions is not appropriate in this scenario. The priority is to improve fetal oxygenation, not to stop contractions.
Choice D rationale
Repositioning the client to a side-lying position can help improve blood flow to the uterus and placenta, enhancing fetal oxygenation. This is a priority intervention.
Choice E rationale
Administering pain medication to the client is not a priority in this situation. The focus should be on addressing fetal distress and improving oxygenation.
Choice F rationale
Administering oxygen to the client increases the oxygen available to the fetus and is a priority intervention when persistent late decelerations are noted.
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