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. While documentation of sensitive material may be a responsibility of the charge nurse, it does not directly relate to educating a newly licensed nurse about the facility's computerized documentation system.
B. Securing client information through measures like installing a firewall is crucial in a computerized documentation system to maintain confidentiality and prevent unauthorized access or data breaches.
C. While password change frequency is an important aspect of maintaining system security, it is not the most critical information to convey to a newly licensed nurse regarding the documentation system.Most facilities require more frequent password changes to enhance security, such as every 60 to 90 days, to mitigate the risk of unauthorized access and potential breaches.
D. Providing access to all client records would violate privacy and security protocols and is not an accurate representation of how the documentation system operates.
Correct Answer is D
Explanation
A. Suctioning or any throat examination should be avoided unless absolutely necessary and then only in a controlled environment such as an operating room because it can provoke airway obstruction.
B. While nutrition is important, the priority in acute epiglottitis is maintaining the airway, not dietary content.
C. This intervention is not related to epiglottitis but to conditions affecting pancreatic function.
D. Epiglottitis is a severe, potentially life-threatening infection, and droplet precautions should be initiated to prevent the spread of infection.
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