A nurse in an antepartum unit is caring for a client.
Blood pressure
Fetal heart rate
Fetal station
Characteristics of amniotic fluid
Duration of contraction
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A child with cystic fibrosis and difficulty clearing secretions is the priority because airway clearance is critical in cystic fibrosis. Mucus buildup can lead to respiratory distress and infection, requiring immediate intervention.
B. A child with an atrial septal defect and a heart rate of 120/min is not the priority because a heart rate of 120/min is within the expected range for a 3-year-old and does not indicate immediate distress.
C. A child with type 1 diabetes and a blood sugar of 150 mg/dL is not the priority because this blood glucose level is slightly elevated but not critical.
D. A child with diarrhea and abdominal pain requires assessment, but dehydration or electrolyte imbalance develops over time. Airway issues take priority over gastrointestinal symptoms.
Correct Answer is C
Explanation
A. "Did anything in particular make you feel this way?" Understanding the cause of the client’s feelings is important, but assessing for immediate safety takes priority.
B. "Would you tell me more about the changes you see in your body?" Exploring the client’s perception of aging is useful, but it does not address potential risk for self-harm.
C. "Do you ever think about harming yourself?" This is the priority assessment question because feelings of worthlessness can indicate depression, which increases the risk of suicide in older adults. Assessing for self-harm ensures immediate safety.
D. "How long have you had these feelings of uselessness?" Identifying the duration of these feelings is relevant, but it is secondary to determining whether the client is at risk for self-harm.
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