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
This is because varicella, or chickenpox, is a highly contagious disease caused by the varicella- zoster virus (VZV), which can spread through the air or by direct contact with the fluid from the blisters. A negative air pressure room prevents the air from the room from circulating to other areas of the hospital, reducing the risk of transmission to other patients and staff.
Choice A is wrong because aspirin should not be given to children with chickenpox, as it can cause a serious condition called Reye’s syndrome, which affects the brain and liver. Instead, acetaminophen can be used to reduce fever.
Choice B is wrong because droplet precautions are not enough to prevent the spread of chickenpox. Droplet precautions involve wearing a mask and gloves when in close contact with the patient, but they do not prevent the virus from traveling through the air. Airborne precautions, which include a negative air pressure room and wearing a respirator, are needed for chickenpox.
Choice D is wrong because Koplik spots are not a sign of chickenpox, but of measles, another viral infection that causes a rash. Chickenpox causes an itchy rash with small, fluid-filled blisters that crust over.
Correct Answer is ["A","B","C","D","E"]
Explanation
The findings that require immediate follow-up are:.
-
- Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states. “My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me.”.
- Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports not wanting to eat anymore. Client’s child reports their parent has lost about 8 lb in the past month.
- Client says. "Why don’t you just leave me? I am of no use.”.
These findings suggest that the client may have cognitive impairment, depression, and/or malnutrition, which can affect their health and quality of life. The nurse should perform a comprehensive assessment of the client’s cognitive, behavioral, and functional status, review their medications and possible side effects, provide education and support for healthy aging, and collaborate with interdisciplinary teams and community resources. The nurse should also evaluate the client’s home environment and lifestyle, and consider nonpharmacological approaches to manage behavioral problems. The nurse should also monitor the client’s vital signs and weight regularly.
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