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A nurse in an antepartum unit is caring for a client.

Exhibits
Select the 2 findings that require immediate follow-up.

A.

Blood pressure

B.

Fetal heart rate

C.

Fetal station

D.

Characteristics of amniotic fluid

E.

Duration of contraction

Answer and Explanation

Correct Answer : B,D

A. Blood pressure: The client’s BP is 128/84 mm Hg, which is within the normal range. Although the client has chronic hypertension, this BP reading does not indicate an immediate concern.

B. Fetal heart rate: The fetal heart rate (FHR) is 165/min, which is tachycardia (normal FHR range is 110–160/min). Fetal tachycardia can indicate infection, maternal fever, fetal distress, or hypoxia and requires immediate follow-up.

C. Fetal station: The station is 0, which means the presenting part is at the level of the ischial spines. This is normal for a laboring client at 4 cm dilation and does not require immediate intervention.

D. Characteristics of amniotic fluid: The fluid is green, indicating the presence of meconium-stained amniotic fluid, which suggests fetal distress or hypoxia. This requires immediate follow-up, as the baby is at risk for meconium aspiration syndrome.

E. Duration of contraction: The contraction lasted 40 seconds, which is within the normal range (30–90 seconds). This is not an immediate concern.


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Related Questions

Correct Answer is C

Explanation

A. Decaffeinated coffee is not recommended for clients with GERD because it can still increase gastric acid secretion, which may worsen symptoms.
B. Tomato soup is acidic and can trigger acid reflux, making it an unsuitable choice for clients with GERD.
C. White fish is a low-fat, non-acidic protein source that is unlikely to trigger GERD symptoms, making it an appropriate dietary choice.
D. Hot cocoa contains chocolate and caffeine, both of which can relax the lower esophageal sphincter (LES) and increase acid reflux.

Correct Answer is B

Explanation

A. Breathlessness is not a typical symptom of a sliding hiatal hernia. However, in severe cases, large hernias may cause shortness of breath due to pressure on the diaphragm.
B. Heartburn (acid reflux) is a common symptom because the hernia allows stomach acid to move up into the esophagus, causing irritation and discomfort.
C. Abdominal cramping is not a primary symptom of a sliding hiatal hernia. Cramping is more commonly associated with gastrointestinal conditions like irritable bowel syndrome (IBS) or gastroenteritis.
D. Constipation is not directly linked to a sliding hiatal hernia. Instead, symptoms usually involve gastroesophageal reflux disease (GERD)-related issues, such as heartburn and regurgitation.

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