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 A
Explanation
A. Keeping the hand elevated above the heart is necessary after carpal tunnel surgery since it minimizes pain and swelling.
B. Heat application is not recommended immediately after carpal tunnel surgery, as it may increase swelling and discomfort.
C. Resting the affected hand allows for proper healing and reduces the risk of complications after carpal tunnel surgery. However, complete non-use for 4-6 weeks is a long period.
D. Numbness and tingling in the hand may be expected immediately after surgery due to residual effects of anesthesia, but it is not a long-term expectation.
Correct Answer is C
Explanation
A. While evaluating uterine tone is part of routine labor monitoring, it does not address the urgent need to relieve pressure on the prolapsed umbilical cord.
B. Keeping the cord moist is less of a priority than immediate measures to relieve pressure on the cord.
C. For a prolapsed umbilical cord, the immediate goal is to relieve pressure on the cord to maintain fetal oxygenation. Placing the client in the Trendelenburg position or a knee-to-chest position can help reduce the pressure on the cord by using gravity to shift the fetal presenting part toward the diaphragm.
D. Applying fundal pressure is contraindicated in the case of umbilical cord prolapse as it can increase pressure on the cord and exacerbate fetal distress.
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