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 B,D,A,C
Explanation
B. Review the skill level and qualifications of each AP.
Before delegating tasks, the nurse should assess the skill level and qualifications of each AP to ensure they have the necessary knowledge and training to perform the assigned tasks safely and effectively.
D. Communicate appropriate tasks to the APs with specific expectations.
The nurse should clearly communicate the tasks to be delegated to each AP. This includes providing specific instructions, expectations, and any necessary information to ensure the APs understand what is expected of them and can perform the tasks correctly.
A. Monitor progress of task completion with each AP.
Once the tasks are assigned, the nurse should periodically check in with each AP to monitor the progress of task completion. This allows the nurse to provide support, answer questions, and ensure that tasks are being performed as expected.
C. Evaluate the APs' performance of each task.
After the tasks are completed, the nurse should evaluate the APs' performance of each task. This evaluation helps identify any areas for improvement, additional training needs, and overall competency of the APs.
Delegating tasks to assistive personnel is an essential aspect of nursing practice. Following this sequence of steps helps ensure that tasks are delegated appropriately and that the care provided is safe, efficient, and aligned with the APs' capabilities. Regular communication and feedback are essential to effective task delegation and teamwork within the healthcare setting.
Correct Answer is B
Explanation
The correct answer is choice b. Using an electronic messaging system to remind clients when to take medications.
Choice A rationale:
Educating clients about contraindications to specific immunizations is an example of primary prevention, which aims to prevent disease before it occurs.
Choice B rationale:
Using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention. It helps manage an existing condition (HIV) by ensuring adherence to treatment, thereby preventing complications and improving quality of life.
Choice C rationale:
Providing clients with information about the benefits of exercise is generally considered primary prevention, as it aims to promote overall health and prevent disease.
Choice D rationale:
Helping clients understand health screenings covered by their insurance plans is an example of secondary prevention, which focuses on early detection and treatment of disease.
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