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
This action helps the client feel more comfortable and less intimidated by the nurse. It also allows the nurse to observe the client’s swallowing and signs of aspiration more easily.
Choice A is wrong because talking with the client during her feeding can distract her from swallowing properly and increase the risk of aspiration.
The nurse should encourage the client to focus on eating and avoid conversation until the feeding is over.
Choice B is wrong because discouraging the client from coughing during feedings can prevent her from clearing her airway and expelling any food particles that might have entered the trachea.
The nurse should monitor the client for coughing, choking, or changes in voice quality, which are indicators of aspiration.
Choice C is wrong because instructing the client to lift her chin when swallowing can actually make swallowing more difficult and increase the risk of aspiration.
The nurse should instruct the client to tuck her chin when swallowing, which helps close off the trachea and direct food into the esophagus.
Correct Answer is C
Explanation
Administer sublingual nitroglycerin.
Nitroglycerin is a vasodilator that can relieve chest pain caused by myocardial ischemia. The nurse should administer it as soon as possible to improve blood flow to the heart and reduce the risk of myocardial infarction. The nurse should also monitor the client’s blood pressure and heart rate after giving nitroglycerin, as it can cause hypotension and reflex tachycardia.
Choice A is wrong because checking a STAT cardiac troponin is not the first priority.
Cardiac troponin is a biomarker that indicates myocardial injury, but it may not rise until several hours after the onset of chest pain.
Therefore, it is not useful for immediate diagnosis or treatment of acute coronary syndrome. Choice B is wrong because requesting a prescription for a beta-blocker is not the first priority.
Beta-blockers are medications that can lower blood pressure and heart rate, and reduce the oxygen demand of the heart.
They can prevent or reduce the recurrence of chest pain and complications of acute coronary syndrome, but they are not indicated for immediate relief of chest pain.
Choice D is wrong because administering oxygen is not the first priority.
Oxygen therapy can increase the oxygen supply to the heart and reduce ischemia, but it is not necessary for all clients with chest pain.
Oxygen therapy should be based on the client’s oxygen saturation level and clinical condition.
If the client’s oxygen saturation is normal or high, oxygen therapy may not be beneficial and may even be harmful.
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