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 D
Explanation
A. It's important not to repeat a dose of digoxin if vomited soon after administration due to the risk of toxicity. Instead, parents should contact their healthcare provider for guidance.
B. Mixing digoxin with a large volume of liquid can lead to inaccurate dosing if the child does not consume all the liquid.
C. Digoxin affects potassium levels in the heart muscle; thus, maintaining a normal dietary intake of potassium is important, not limiting it, as hypokalemia can increase the risk of digoxin toxicity.
D. Having water after taking digoxin helps ensure that the medication is swallowed completely and minimizes the risk of esophageal irritation. It aids in proper absorption of the drug.
Correct Answer is C
Explanation
A. Eating a meal before postural drainage could increase the risk of aspiration during the procedure.
B. Completing oral hygiene is good practice but not directly related to postural drainage.
C. Albuterol can help open the airways, making the postural drainage process more effective.
D. Pancrelipase is a medication to aid in digestion and is not directly related to the initiation of postural drainage.
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