A nurse is monitoring a client who is in the active phase of labor and has an electronic fetal monitor.
Which of the following findings should the nurse expect?
Uterine contractions every 15 min.
FHR baseline 166/min with minimal variability.
Late decelerations in FHR.
Contraction duration of 75 seconds.
The Correct Answer is D
Choice A rationale
Uterine contractions occur more frequently than every 15 minutes during the active phase of labor, typically every 2-3 minutes.
Choice B rationale
A fetal heart rate baseline of 166/min is considered tachycardia and may not be normal during labor.
Choice C rationale
Late decelerations are concerning and not expected as they may indicate fetal distress.
Choice D rationale
Contractions lasting about 75 seconds are expected during the active phase of labor.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
Choice A rationale
Feeding from only one breast can lead to engorgement and a decrease in milk supply in the affected breast. It is important to continue breastfeeding from both breasts, even if one is infected.
Choice B rationale
Discarding milk is not necessary and can lead to a decrease in milk supply. The infection does not harm the baby, and breastfeeding helps to drain the breast and clear the infection.
Choice C rationale
Moist heat can help to increase blood flow and promote healing in the affected breast. Applying warm compresses or taking warm showers can help to reduce pain and inflammation associated with mastitis.
Choice D rationale
While staying hydrated is important for overall health, there is no specific requirement to drink at least 1500 milliliters of fluid per day for mastitis. Adequate fluid intake should be maintained, but there is no direct correlation with resolving the infection.
Correct Answer is B
Explanation
Choice A rationale
Monitoring blood pressure every 30 minutes following epidural placement is important but not the initial action. Epidural anesthesia can lead to a sudden drop in blood pressure, so
frequent monitoring is crucial. However, the initial step should focus on preventing hypotension.
Choice B rationale
Administering lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement helps in maintaining blood pressure. Epidural anesthesia can cause vasodilation,
leading to hypotension. Preloading with fluids ensures adequate blood volume and reduces the risk of a significant drop in blood pressure.
Choice C rationale
Administering oxygen via nasal cannula at 2 L/min prior to epidural placement is not necessary unless the client has respiratory complications. Oxygen supplementation is used to
treat or prevent hypoxia, which is not a primary concern in this scenario.
Choice D rationale
Repositioning the client every hour following epidural placement is important to ensure even distribution of the anesthetic and prevent pressure sores. However, this is not the initial
action to take for preventing hypotension.