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 D
Explanation
The correct answer is choiceD. Remind the client to use the incentive spirometer.
Choice A rationale:
Observing the position of the suspended weight requires clinical judgment to ensure proper alignment and effectiveness of the traction, which is beyond the scope of practice for assistive personnel.
Choice B rationale:
Checking the client’s pedal pulse on the right leg involves assessing circulation, which is a clinical task that should be performed by a licensed nurse.
Choice C rationale:
Asking the client to describe her pain involves pain assessment, which requires clinical judgment and should be done by a nurse.
Choice D rationale:
Reminding the client to use the incentive spirometer is a task that can be delegated to assistive personnel as it involves reinforcing previously taught instructions without requiring clinical judgment.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
Answer is…
The following provider prescriptions are anticipated or contraindicated for the client:.
- Insert an indwelling urinary catheter. Anticipated. This prescription is anticipated because the client may have oliguria or anuria due to dehydration, hypovolemia, or renal impairment caused by pancreatitis. A urinary catheter can help monitor the urine output and fluid status of the client.
- Insert a nasogastric tube and maintain low intermittent suction. Anticipated. This prescription is anticipated because the client may have nausea, vomiting, and abdominal distension due to pancreatitis. A nasogastric tube can help decompress the stomach, reduce pancreatic stimulation, and prevent aspiration.
- Administer lactated Ringer’s 1 L via IV bolus. Anticipated. This prescription is anticipated because the client may have hypovolemia, hypotension, and electrolyte imbalances due to pancreatitis. Lactated Ringer’s solution can help restore fluid and electrolyte balance, improve tissue perfusion, and prevent shock.
- Administer famotidine 20 mg via intermittent IV infusion twice daily. Anticipated. This prescription is anticipated because the client may have gastric hypersecretion and peptic ulcer disease due to pancreatitis. Famotidine is a histamine-2 receptor antagonist that can help reduce gastric acid production, protect the gastric mucosa, and promote healing of ulcers.
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