The Assessment Patient Process
The Assessment Patient Process ( 6 Questions)
A nurse is assessing a client who is in the first stage of labor.
Which finding should the nurse report to the provider immediately?
This is a normal finding for the first stage of labor, which lasts until the cervix is fully dilated to 10 cm.
A fetal heart rate of 180 beats per minute is above the normal range of 110 to 160 beats per minute and indicates fetal distress. The nurse should report this finding to the provider immediately and prepare for interventions to improve fetal oxygenation, such as changing the client's position, administering oxygen, or initiating a fluid bolus.
This is a normal finding for the active phase of the first stage of labor, which occurs when the contractions are 3 to 5 minutes apart and last for 40 to 60 seconds.
This is a normal finding that indicates the absence of infection or meconium staining in the amniotic fluid.
The client's fetal heart rate is 180 beats per minute.
Rationale: A fetal heart rate of 180 beats per minute is above the normal range of 110 to 160 beats per minute and indicates fetal distress. The nurse should report this finding to the provider immediately and prepare for interventions to improve fetal oxygenation, such as changing the client's position, administering oxygen, or initiating a fluid bolus.
Incorrect options:
A) The client's cervix is dilated to 4 cm. - This is a normal finding for the first stage of labor, which lasts until the cervix is fully dilated to 10 cm.
C) The client's contractions are 5 minutes apart. - This is a normal finding for the active phase of the first stage of labor, which occurs when the contractions are 3 to 5 minutes apart and last for 40 to 60 seconds.
D) The client's amniotic fluid is clear and odorless. - This is a normal finding that indicates the absence of infection or meconium staining in the amniotic fluid.