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)

Answer and Explanation

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.

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Correct Answer is B

Explanation

A: Heparin administration requires careful monitoring of clotting times, so discharging this client early may not be safe or appropriate.
B: A vertebroplasty is a procedure that injects cement into a fractured vertebra to help relieve pain and stabilize the spine. The recovery time for this procedure is usually short and the complications are rare.
C: This client has a respiratory rate suggestive of respiratory distress and may require immediate medical attention, hence early discharge is not an option.
D: The client with cancer and a sealed implant for radiation therapy may require ongoing monitoring and supportive care, so early discharge may not be advisable.

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

Correct Answer is C

Explanation

A: Percussion should be performed with a cupped hand to provide effective airway clearance, not with a flat hand.
B: Postural drainage is typically performed multiple times per day to help clear secretions from the lungs in cystic fibrosis.
C: Postural drainage is often performed before meals to minimize the risk of vomiting due to manipulation of the abdomen.
D: Bronchodilators are not typically administered after postural drainage; they are used to help open the airways before the procedure.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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