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

Exhibits

Click to highlight the findings that indicate the interventions have been effective. To deselect a finding, click on the finding again.

Nurses' Notes

2230:

Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min with moderate variability. Accelerations present, no decelerations noted.

Vital Signs

2230:

Temperature 38° C (100.4° F)

Heart rate 88/min

Respiratory rate 16/min

Blood pressure 122/80 mm Hg

Oxygen saturation 98% on room air

A.

Client rates pain with contractions as a 3 on a scale of 0 to 10

B.

FHR 150/min with moderate variability. Accelerations present, no decelerations noted

C.

Heart rate 88/min

D.

Respiratory rate 16/min

E.

Blood pressure 122/80 mm Hg

F.

Oxygen saturation 98% on room air

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

  • Heart rate decreased from 104/min to 88/min, indicating improved hemodynamic stability.
  • Respiratory rate decreased from 20/min to 16/min, suggesting relaxation and reduced distress.
  • Blood pressure slightly decreased from 132/84 mm Hg to 122/80 mm Hg, indicating improved comfort and reduced pain-related stress response.
  • Pain level decreased to 3/10 after epidural placement, demonstrating effective pain management.
  • FHR 150/min with moderate variability and accelerations present, no decelerations, indicating fetal well-being.


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Related Questions

Correct Answer is C

Explanation

A. Bradycardia is not expected with dehydration. Instead, tachycardia occurs as a compensatory response to low blood volume.
B. Edema is not a symptom of dehydration. Instead, dehydration leads to decreased tissue perfusion and dry mucous membranes.
C. Hypotension occurs due to decreased blood volume from fluid loss, leading to low blood pressure and potential dizziness or weakness.
D. Crackles are not expected in dehydration. Instead, lung sounds are typically clear unless another condition is present.

Correct Answer is D

Explanation

A. Antibiotic therapy. This is incorrect because there is no indication of an infection. The WBC count is within the normal range, and there are no symptoms suggestive of a bacterial infection.
B. Protective environment. This is incorrect because a protective environment is used for immunocompromised clients, such as those undergoing chemotherapy or with severe neutropenia, which is not the case here.
C. Blood transfusion. This is incorrect because although the hemoglobin level is low (8.1 g/dL), it is not critically low enough to require a transfusion. Instead, iron supplementation is the preferred treatment.
D. Iron supplementation. This is correct because the child’s hemoglobin and hematocrit levels indicate mild anemia, likely due to excessive cow’s milk intake, which can lead to iron deficiency anemia in toddlers. Iron supplementation will help correct the deficiency.

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