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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. The guardian wants to accompany the child from the ED to the radiology department. This is a typical parental response and does not indicate maltreatment. Parents often want to stay with their child for reassurance.
B. The guardian states the child fell off the swing in the backyard. This is a plausible explanation for an injury in a preschooler, though the consistency of the story with the injury should still be assessed.
C. The child was brought to the ED 2 days after the injury occurred. A delay in seeking medical care for a significant injury is a potential warning sign of child maltreatment and warrants further investigation.
D. The child cries loudly when their arm is moved or manipulated. Pain with movement is expected with a fracture and does not indicate maltreatment.

Correct Answer is B

Explanation

A. "Store unused patches in the refrigerator." Scopolamine patches should be stored at room temperature, not in the refrigerator.
B. "Apply the patch prior to traveling." The patch should be applied at least four hours before travel to allow time for absorption and effectiveness.
C. "Place the patch on your upper arm." The patch should be applied behind the ear, not on the upper arm, for optimal absorption.
D. "Replace a dislodged patch onto the same location." A new patch should be applied to a different area to prevent skin irritation.

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