When monitoring uterine contractions in a client in the active phase of the first stage of labor, which finding should the nurse report to the provider?

Correct Answer: A

Rationale: Rationale: Contractions lasting longer than 90 seconds can indicate uterine hyperstimulation, which can lead to decreased oxygenation of the fetus. This finding should be reported to the provider for further assessment and intervention. Contractions occurring every 3 to 5 minutes (choice B) are normal in the active phase of labor. Strong contractions (choice C) are also expected during this phase. Feeling contractions in the lower back (choice D) is common and not typically a cause for concern. Reporting contractions lasting longer than 90 seconds is crucial to ensure the safety of both the mother and the baby.

Correct Answer: A

Rationale: The correct answer is A: Apply an ice pack to the affected area. Ice helps reduce inflammation and numb the pain, providing relief for the client. Step 1: Ice constricts blood vessels, reducing swelling and pain. Step 2: Ice numbs the area, providing immediate relief. Step 3: Ice is recommended for acute pain management. Summary: B (warm sitz bath) may increase blood flow and exacerbate swelling. C (antiseptic solution) is not indicated for pain relief. D (hot pack) may worsen inflammation and pain.

Correct Answer: D

Rationale: Rationale: 1. Lochia rubra and small clots are expected postpartum. 2. The firm, midline fundus indicates normal involution. 3. No signs of excessive bleeding or fundus displacement. 4. Documenting and monitoring is appropriate for normal postpartum assessment. Summary: A: Not necessary as no complications present. B: Unnecessary and could cause discomfort. C: Bladder emptying may help fundal position but not urgent. D: Correct option for normal postpartum assessment and monitoring.

Correct Answer: B

Rationale: The correct answer is B: Document this as an expected finding. A heart rate of 130/min in a newborn is within the normal range (120-160/min). The nurse should document this as an expected finding because it indicates a healthy heart rate for a newborn. There is no immediate need for intervention or further assessment as the heart rate falls within the normal range for a newborn. Asking another nurse to verify the heart rate (choice A) is unnecessary as it is within the normal range. Calling the provider to further assess the newborn (choice C) is not needed since the heart rate is normal. Preparing the newborn for transport to the NICU (choice D) is not indicated as the heart rate is within the normal range.

Correct Answer: B

Rationale: The correct answer is B (15 to 25 pounds) because this recommendation aligns with the guidelines for weight gain during pregnancy for a client with a BMI of 26.5. The Institute of Medicine recommends this weight gain range for individuals in the overweight category. It is important to strike a balance between gaining enough weight to support the health of the fetus and not gaining excess weight that may lead to complications. Choice A (11 to 20 pounds) may not provide enough weight gain for optimal pregnancy outcomes, while choice C (25 to 35 pounds) may lead to excessive weight gain. Choice D (1 pound per week) is too specific and does not account for individual variations in weight gain patterns during pregnancy. It is crucial to tailor weight gain recommendations based on the client's BMI to ensure a healthy pregnancy.