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).

Answer and Explanation

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.

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Correct Answer is D

Explanation

Nail polish remover contains acetone, which is a flammable substance that can ignite in the presence of oxygen. Using nail polish remover around the client can increase the risk of fire and burn injuries.

Choice A is wrong because synthetic fabrics can generate static electricity, which can also cause sparks and ignite oxygen.

The client’s bedding should be made of cotton or wool, which are natural fabrics that do not produce static electricity.

Choice B is wrong because petroleum jelly is a petroleum-based product that can react with oxygen and cause skin irritation or burns.

The client should use water-based moisturizers to soothe the mucous membranes.

Choice C is wrong because alcohol-based cleaning products are also flammable and can cause fires or explosions when exposed to oxygen.

The client should use mild soap and water to clean the equipment, and follow the manufacturer’s instructions for maintenance.

Some general safety tips for home oxygen therapy are:

Keep away from heat and flame, such as candles, matches, lighters, stoves, fireplaces, etc.
Do not smoke or allow others to smoke near the oxygen source
Do not use aerosols, vapor rubs, oils, or other products that contain flammable substances near the oxygen source
Store oxygen tanks or cylinders in a well-ventilated area away from direct sunlight and heat sources
Secure oxygen tanks or cylinders to prevent them from falling or rolling
Use the exact rate of oxygen prescribed by the doctor for each activity
Check the oxygen gauge or level regularly and call the medical supply company when it is low
Use a humidifier bottle if prescribed by the doctor to prevent dryness of the mucous membranes
Change the nasal cannula, mask, and tubing as instructed by the medical supply company to prevent

A. Assess the child for frequent swallowing. B. Continuously monitor the child’s respiratory status. C. Carefully suction the child’s oropharynx to remove secretions. D. Administer pancreatic enzymes with meals.

Correct Answer is B

Explanation

This is because epiglottitis is a life-threatening condition that can cause severe airway obstruction and respiratory distress in children. The nurse should monitor the child for signs of worsening breathing, such as stridor, cyanosis, restlessness, or drooling. The nurse should also be prepared to assist with intubation or tracheostomy if needed.
Choice A is wrong because assessing the child for frequent swallowing may increase the risk of vomiting and aspiration. Swallowing may also be difficult and painful for the child due to the inflammation of the epiglottis.
Choice C is wrong because suctioning the child’s oropharynx may cause more swelling and irritation of the epiglottis, or trigger a spasm that can close off the airway. The nurse should avoid any stimulation of the throat or mouth that may worsen the condition.
Choice D is wrong because administering pancreatic enzymes with meals is not relevant to epiglottitis. Pancreatic enzymes are used to treat cystic fibrosis, a genetic disorder that affects the lungs and digestive system. Epiglottitis is caused by a bacterial infection or an injury to the throat.

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A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?

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A nurse is assessing a client who is in active labor.

Which of the following findings should the nurse report to the provider?