A nurse is assessing a client who is in active labor.
Which of the following findings should the nurse report to the provider?
Early decelerations in the FHR.
Contractions lasting 80 seconds.
FHR baseline 170/min.
Temperature 37.4° C (99.3° F).
The Correct Answer is C
This is because a normal FHR baseline is between 110 and 160 bpm, and anything above or below this range indicates fetal distress and should be reported to the provider. An FHR baseline of 170/min could indicate fetal tachycardia, which could be caused by maternal fever, infection, dehydration, fetal anemia, or fetal hypoxia.
Choice A is wrong because early decelerations in the FHR are normal and benign, and indicate head compression during contractions.
They do not require any intervention or reporting.
Choice B is wrong because contractions lasting 80 seconds are within the normal range for active labor, which is 40 to 90 seconds per contraction.
They do not indicate any complication or abnormality.
Choice D is wrong because a temperature of 37.4° C (99.3° F) is slightly elevated but not considered a fever. A fever is defined as a temperature of 38° C (100.4° F) or higher.
A mild increase in temperature could be due to dehydration, exertion, or environmental factors, and does not necessarily indicate infection or inflammation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Partial separation of the upper part of the incisional line.
This is a sign of wound dehiscence, which is a serious complication that occurs when the edges of a surgical incision separate and the underlying tissues are exposed.
Wound dehiscence can lead to infection, bleeding, and evisceration (protrusion of internal organs through the incision). The nurse should report this finding to the provider immediately and cover the wound with a sterile dressing moistened with sterile saline solution.
Choice A is wrong because mild swelling under the sutures near the incisional line is a normal finding in the early stages of wound healing. It does not indicate infection or dehiscence unless accompanied by other signs such as redness, warmth, pain, or purulent drainage.
Choice B is wrong because crusting of exudate on the incisional line is also a normal finding that indicates the formation of a scab.
A scab protects the wound from infection and helps it heal faster. The nurse should not remove the scab unless instructed by the provider.
Choice D is wrong because pink-tinged coloration on the incisional line is another normal finding that shows healthy granulation tissue.
Granulation tissue is new tissue that fills in the wound and helps it close. It is usually pink or red and moist.
The nurse should follow these general tips for postoperative abdominal incision care:
- Always wash your hands before and after touching your incisions.
- Inspect your incisions and wounds every day for signs your healthcare provider has told you are red flags or concerning.
- Look for any bleeding.
If the incisions start to bleed, apply direct and constant pressure to the incisions.
- Avoid wearing tight clothing that might rub on your incisions.
- Try not to scratch any itchy wounds.
- You can shower starting 48 hours after your operation but no scrubbing or soaking of the abdominal wounds in a tub.
- After the initial dressing from the operating room is removed, you can leave the wound open to air unless there is drainage or you feel more comfortable with soft gauze covering the wound.
- Surgical glue (Indermil) will fall off over a period of up to 2-3 weeks. Do not put any topical ointments or lotions on the incisions.
- Do not rub over the incisions with a washcloth or towel.
- No tub baths, hot tubs, or swimming until evaluated at your clinic appointment.
Correct Answer is D
Explanation
The correct answer is Choice D, "We can provide a copy of your records, but the therapist's notes are not included."
Rationale for Choice A:
- Puts the client on the defensive:Asking "Why are you interested in seeing your therapist's notes?" can make the client feel like they need to justify their request,potentially leading to defensiveness or withdrawal.
- May not uncover true motivation:The client may not feel comfortable revealing their true reasons for wanting to see the notes,and this approach could hinder open communication.
- Undermines client autonomy:It's important to respect the client's right to access their own information,even if it's not always beneficial.Questioning their motives could make them feel less empowered in their treatment.
Rationale for Choice B:
- Paternalistic and dismissive:Saying "I don't think you will benefit from reviewing your therapist's notes right now" assumes that the nurse knows what's best for the client without exploring their perspective.
- Discourages open communication:It shuts down conversation and may prevent the client from expressing their concerns or needs.
- Could damage therapeutic relationship:By dismissing the client's request,the nurse risks eroding trust and rapport,which are essential for effective therapy.
Rationale for Choice C:
- Assumes dissatisfaction with treatment:Asking "Are you not happy with your treatment?" immediately focuses on potential problems rather than understanding the client's motivations.
- May not be accurate:The client's request may not stem from dissatisfaction with treatment but rather from curiosity,a desire for control,or other reasons.
- Could create unnecessary anxiety:Raising concerns about treatment satisfaction without proper exploration could create anxiety or doubts in the client's mind.
Rationale for Choice D:
- Clear and informative:It directly addresses the client's request while providing accurate information about the availability of records.
- Protects therapist's notes:It upholds the therapist's right to maintain confidentiality of their thought processes and clinical impressions.
- Offers alternative solutions:It suggests that the client can access other parts of their record,potentially addressing their underlying need for information.
- Professional and respectful:It maintains professional boundaries and respects the client's right to information without disclosing protected notes.
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