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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 {"dropdown-group-1":"E","dropdown-group-2":"E"}

Explanation

The nurse should prepare to administer naloxone and oxygen by face mask 10 L/min.

Rationale:

  • Naloxone is used to reverse opioid-induced respiratory depression, which is a potential risk during moderate sedation.
  • Oxygen by face mask 10 L/min is necessary to maintain adequate oxygenation during and after sedation, as respiratory depression can occur.
  • Acetaminophen is not used for immediate management of sedation-related complications.
  • An additional dose of fentanyl or propofol would deepen sedation, not manage its complications.
  • Propranolol is a beta-blocker that is not indicated in this situation.

Correct Answer is C

Explanation

A. Have the client hold their breath during the examination. This is not recommended, as slow, deep breathing helps the client relax and reduces discomfort.
B. Ensure that the client's bladder is full. The bladder should be emptied before the exam to enhance comfort and allow better access for the provider.
C. Instruct the client to bear down when the speculum is inserted. This helps relax the pelvic muscles and makes insertion easier, reducing discomfort.
D. Place the client in modified Sims' position. The lithotomy position is the correct positioning for a pelvic examination, not modified Sims'.

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