What should the nurse do if the fetal monitor shows average variability with a baseline of 142 bpm?

Correct Answer: A

Rationale: The correct answer is to provide caring labor support (Choice A). Average variability in fetal heart rate (FHR) indicates a normal fluctuation in the baby's heart rate, which is a reassuring sign of fetal well-being. The baseline heart rate of 142 bpm is within the normal range of 110-160 bpm. In this situation, the nurse should focus on providing emotional support, comfort measures, and encouragement to the laboring mother. This can help reduce anxiety, promote relaxation, and facilitate the progress of labor. Administering oxygen via face mask (Choice B) is typically indicated for fetal distress, not for average variability. Oxygen therapy is used to improve oxygenation to the fetus in cases of non-reassuring FHR patterns such as late decelerations or decreased variability. Changing the client's position (Choice C) can be beneficial in optimizing fetal oxygenation and blood flow during labor. However, in this scenario of average variability with a normal baseline heart rate, there is no immediate need to change positions unless there are other signs of fetal distress. Speeding up the client's intravenous (Choice D) is not necessary based on the information provided. Increasing the rate of IV fluids would not address the issue of average variability in FHR. It is important to monitor the IV fluids to maintain hydration and ensure proper fetal perfusion, but there is no indication to speed up the IV based solely on the FHR tracing described.

Correct Answer: C

Rationale: Choice A: "If I feel a pain in my back and lower abdomen every 5 minutes." This statement indicates the client is experiencing contractions every 5 minutes, which could be a sign of labor starting. This is a valid reason to go to the hospital, as frequent contractions are a common indication of labor. Therefore, this statement does not indicate a need for additional teaching. Choice B: "When I feel a gush of clear fluid from my vagina." This statement suggests the client's water may have broken, which is another valid reason to go to the hospital. A gush of clear fluid can be a sign that the amniotic sac has ruptured, indicating the start of labor. Therefore, this statement does not indicate a need for additional teaching. Choice D: "If I notice greenish discharge from my vagina." Greenish discharge could be a sign of infection, particularly if it is accompanied by a foul odor or itching. While this may not necessarily require immediate hospitalization, it does warrant medical attention to rule out any potential complications. However, it is not a clear indication of when to go to the hospital during pregnancy and childbirth. Therefore, this statement does not indicate a need for additional teaching. Correct Answer - Choice C: "When I see the mucus plug on toilet tissue." The mucus plug is a collection of thick mucus that blocks the cervical canal during pregnancy, providing a barrier against infection. Losing the mucus plug can be a sign that labor is approaching, but it does not necessarily mean the client needs to go to the hospital immediately. It is more of an early sign of labor rather than an emergency situation. Therefore, this statement indicates a need for additional teaching on when to go to the hospital during pregnancy and childbirth.

Correct Answer: D

Rationale: Contractions every 3 minutes lasting 60 seconds means there is a contraction for 1 minute followed by a rest period of 2 minutes. This is equivalent to option D, which states contractions lasting 1 minute followed by a 120-second rest period. Option A is incorrect because it describes contractions lasting 60 seconds followed by a 1-minute rest period, which does not match the given scenario of contractions every 3 minutes. Option B is incorrect as it describes contractions lasting 120 seconds followed by a 2-minute rest period, which is not consistent with contractions every 3 minutes lasting 60 seconds. Option C is incorrect because it describes contractions lasting 2 minutes followed by a 60-second rest period, which is not in line with the specified pattern of contractions every 3 minutes lasting 60 seconds. In conclusion, option D is the correct answer as it aligns with the given scenario of contractions every 3 minutes lasting 60 seconds, with a contraction lasting 1 minute followed by a rest period of 2 minutes.

Correct Answer: D

Rationale: The correct answer is D: True contractions. The client's report of contractions that started 2 hours ago, did not alleviate with rest and hydration, intensified with movement, and were accompanied by blood suggests that she is experiencing true contractions. True contractions are regular, rhythmic, and become more intense over time. The presence of blood can indicate cervical changes and is a sign of progressing labor. Choice A: Braxton Hicks contractions are irregular, painless contractions that do not indicate the onset of labor. They typically decrease with rest, hydration, or a change in activity. The client's symptoms do not align with the characteristics of Braxton Hicks contractions. Choice B: Rupture of membranes would be accompanied by a gush of fluid, not just blood when wiping after voiding. The absence of fluid leakage from the vagina makes this choice incorrect. Choice C: Fetal descent refers to the movement of the fetus through the birth canal during labor. While the client may be experiencing fetal descent, the primary concern in this scenario is the presence of true contractions based on the reported symptoms.

Correct Answer: B

Rationale: The correct answer is B: 4-1-2-0-4. Gravidity refers to the total number of pregnancies a woman has had, including the current one. Parity refers to the number of pregnancies that have reached viability. The GTPAL system breaks down a woman's obstetric history into Gravidity, Term births, Preterm births, Abortions/miscarriages, and Living children. In this case, the woman is pregnant for the fourth time, so her gravidity is 4. She has had one term birth (39 weeks gestation), two preterm births (34 and 35 weeks gestation), no abortions/miscarriages, and all her children from previous pregnancies are living. Let's break down each choice: A: 3-1-1-1-3 - Gravidity of 3 is incorrect as the woman is pregnant for the fourth time. - Parity of 1 is correct as she has had one term birth. - Two preterm births are incorrect. - One abortion/miscarriage is incorrect. - Living children of 3 is incorrect. C: 3-0-3-0-3 - Gravidity of 3 is incorrect. - Parity of 0 is incorrect as she has had one term birth. - Three preterm births are incorrect. - No abortions/miscarriages is incorrect. - Living children of 3 is incorrect. D: 4-2-1-0-3 - Gravidity of 4 is correct. - Parity of 2 is incorrect as she has had one term birth. - One preterm birth is correct. - No abortions/miscarriages is correct. - Living children of 3 is incorrect. Therefore, the correct answer is B: 4-1-2-0-4, as it accurately represents the woman's obstetric history.