Question

Vital Signs

0900:Temperature 36.6° C (97.9° F)Heart rate 88/minRespiratory rate 18/minBlood pressure 130/70 mm HgOxygen saturation 97% on room air000:Heart rate 76/minRespiratory rate 20/minBlood pressure 138/68 mm HgOxygen saturation 98% on room air
Medical History
0900:Gravida 3, Para 232 weeks of gestationClient reports cramping and lower back pain that started this morning. Client denies leaking fluid.
Nurses' Notes
0900:Client placed on electronic fetal monitor. Client reports pain as 4 on a scale of 0 to 10.
1000:FHR assessment 150/min. Average variability. No decelerations. Spontaneous accelerations noted.Uterine contractions occurring every 2 min, lasting 40 to 60 seconds in duration. Palpate as moderate intensity.Vaginal examination performed. Cervix is 2 cm dilated and 50% effaced.

Which of the following findings should the nurse report to the provider?
Select the 3 findings that should be reported.

Answer 1

The nurse should report uterine contractions every 2 minutes, cervical dilation of 2 cm and 50% effacement, and fetal heart rate with spontaneous accelerations, as they could indicate preterm labor.

Step-by-step explanation:

The student is tasked with identifying three findings from the clinical scenario that should be reported to the medical provider. The scenario involves a pregnant client at 32 weeks of gestation who has reported cramping and lower back pain. The three findings that warrant reporting are the uterine contractions every 2 minutes, the cervical dilation of 2 cm with 50% effacement, and the fetal heart rate assessment showing spontaneous accelerations with no decelerations. These findings suggest that the client may be in preterm labor, which requires immediate medical attention to assess and manage potential risks to both the mother and fetus.