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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?

A.

Uterine contractions every 15 min.

B.

FHR baseline 166/min with minimal variability.

C.

Late decelerations in FHR.

D.

Contraction duration of 75 seconds.

Answer and Explanation

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.


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

A positive pregnancy test is a probable sign of pregnancy as it indicates the presence of hCG, a hormone produced during pregnancy. However, it is not a presumptive sign, as other

conditions can also result in elevated hCG levels.

Choice B rationale

Amenorrhea, or the absence of menstrual periods, is a presumptive sign of pregnancy. It is one of the earliest indications that a woman may be pregnant, though it can also be

caused by other factors such as stress or hormonal imbalances.

Choice C rationale

Fetal heart sounds detected by Doppler ultrasound are a positive sign of pregnancy, confirming the presence of a fetus. This is not a presumptive sign as it is direct evidence of

pregnancy.

Choice D rationale

Chadwick's sign, a bluish discoloration of the cervix, vagina, and labia due to increased blood flow, is considered a probable sign of pregnancy. It is not a presumptive sign but rather

a physical change that occurs during pregnancy. .

Correct Answer is A

Explanation

Choice A rationale

Suctioning the mouth and nose ensures that the airway is clear of any meconium-stained fluid, which can cause respiratory issues in the newborn if inhaled.

Choice B rationale

While skin-to-skin contact is beneficial for bonding and temperature regulation, ensuring the airway is clear is a higher immediate priority.

Choice C rationale

Placing the newborn under a radiant warmer helps maintain body temperature but is secondary to ensuring the airway is clear of meconium-stained fluid.

Choice D rationale

Tactile stimulation is important for encouraging breathing, but first ensuring the airway is clear takes precedence.

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