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

Temperature 37.4° C (99.3° F)

Early decelerations in the FHR

Contractions lasting 80 seconds

FHR baseline 170/min

Answer and Explanation

The Correct Answer is D

A. Temperature 37.4° C (99.3° F): This is a mild elevation and within normal limits for a laboring client. Slight temperature increases can occur due to physical exertion and are not typically concerning.

B. Early decelerations in the FHR: Early decelerations are usually benign and mirror uterine contractions, reflecting fetal head compression. They are not an indication for immediate intervention.

C. Contractions lasting 80 seconds: Normal uterine contractions in active labor typically last 45–80 seconds. While the upper limit of 80 seconds is noted, this alone does not require urgent reporting if the contraction pattern and fetal response remain reassuring.

D. FHR baseline 170/min: A baseline fetal heart rate above 160/min indicates fetal tachycardia, which can result from maternal infection, fetal hypoxia, or other complications. This finding requires prompt notification of the provider for further evaluation and potential intervention.

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Correct Answer is C

Explanation

A. Use a 15° angle for the injection: Subcutaneous insulin injections should be administered at a 90° angle for most adults and children with adequate subcutaneous tissue. A 15° angle is too shallow and may result in intradermal administration, affecting absorption.

B. Roll the syringe gently to ensure mixture of the insulins: Only the NPH insulin vial should be gently rolled between the hands to resuspend the cloudy insulin. Regular insulin is clear and should not be shaken, and the mixture occurs in the syringe after drawing up each insulin in the correct sequence.

C. Draw up regular insulin prior to NPH insulin: Drawing up regular (clear) insulin before NPH (cloudy) insulin prevents contamination of the short-acting insulin with intermediate-acting insulin, maintaining proper pharmacologic action and preventing altered onset or peak times.

D. Inject into the vastus lateralis: The preferred sites for subcutaneous insulin injections are the abdomen, upper arm, or anterior thigh. The vastus lateralis can be used in infants but is not the standard site for older children or adults.

A. Administer a bronchodilator after the procedure. B. Perform the procedure prior to meals. C. Perform the procedure twice each day. D. Hold hand flat to perform percussions on the child.

Correct Answer is B

Explanation

A. Administer a bronchodilator after the procedure: Bronchodilators are usually administered before postural drainage and percussion to open the airways, enhance mucus clearance, and reduce bronchospasm. Administering afterward would not optimize airway clearance.

B. Perform the procedure prior to meals: Performing postural drainage before meals helps prevent nausea and vomiting, which can occur if the stomach is full. This timing also enhances comfort and safety during chest physiotherapy for children with cystic fibrosis.

C. Perform the procedure twice each day: Children with cystic fibrosis often require more frequent airway clearance, sometimes three to four times daily, depending on clinical status. Limiting it to twice daily may be insufficient to prevent mucus accumulation.

D. Hold hand flat to perform percussions on the child: Percussions should be performed with cupped hands, not flat hands, to create a vibration that loosens mucus in the airways. Flat-hand technique is ineffective and does not facilitate optimal airway clearance.

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Body System	Findings
Gastrointestinal	Client states, "I'm nauseated all the time. I vomit a few times a day, too." Client states, "I've been a little constipated, but it's not too bad." Abdomen without tenderness on palpation. Bowel sounds hypoactive. Oral mucous membranes sticky.
Genitourinary	Also reports they are urinating less and that urine is dark yellow and odorous. Clean-catch urine specimen obtained. Urine noted to be dark yellow and concentrated
Cardiovascular	Heart rate regular. No edema. Heart rate 92/min Blood pressure 102/66 mm Hg

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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