A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
Contractions lasting 80 seconds
Early decelerations in the FHR
FHR baseline 170/min
Temperature 37.4° C (99.3° F)
The Correct Answer is C
A. Contractions lasting 80 seconds, while prolonged, may occur in active labor and do not necessarily indicate a complication requiring immediate provider notification.
B. Early decelerations in the fetal heart rate are typically benign and are not typically concerning unless they are persistent or associated with other signs of fetal distress.
C. An FHR baseline of 170/min is above the normal range and may indicate fetal distress or other complications requiring further evaluation and possible intervention, necessitating prompt provider notification.
D. A temperature of 37.4°C (99.3°F) is within the normal range and does not typically require immediate provider notification unless accompanied by other concerning symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Facilitating problem-solving skills is typically more relevant during the working phase of the therapeutic relationship, not the orientation phase.
B: During the orientation phase, establishing clear roles and responsibilities helps set expectations and boundaries for the therapeutic relationship.
C: Assisting the client in expressing alternative behaviors is also more relevant during the working phase when exploring and implementing change.
D: Determining previous coping skills is important but typically occurs during the assessment phase, which precedes the orientation phase of the therapeutic relationship.
Correct Answer is B
Explanation
A. Providing a cooling blanket may help reduce fever associated with a thyroid storm but is not the priority over monitoring the cardiac rhythm.
B. In a thyroid storm, the client is at risk for severe cardiovascular complications, including tachycardia, arrhythmias, and heart failure. Therefore, the nurse's priority action is to monitor the client's cardiac rhythm continuously to detect any abnormalities promptly and intervene as needed.
C. Administering 0.9% sodium chloride IV may be necessary to maintain fluid balance, but it's not the priority over cardiac monitoring.
D. Obtaining the client's blood glucose may be relevant but is not the priority in the acute management of a thyroid storm.
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