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. Positioning the client over an overbed table is not appropriate for a paracentesis procedure and may interfere with the procedure.
B. Emptying the bladder before the procedure helps to reduce the risk of accidental bladder puncture during paracentesis.
C. Administering IV fluids prior to the procedure is not typically indicated for a paracentesis, unless specifically ordered by the provider for hydration purposes.
D. NPO status is not typically required before a paracentesis procedure unless otherwise specified by the provider.
Correct Answer is D
Explanation
A. Splitting behavior, where the client views people and situations as either all good or all bad, is more characteristic of borderline personality disorder rather than histrionic personality disorder.
B. Emotional lability, characterized by rapid shifts in mood, is not a primary feature of histrionic personality disorder.
C. Unexpressive affect, or a lack of emotional expression, is not a typical feature of histrionic personality disorder, which often presents with exaggerated and dramatic emotional displays.
D. Self-centered behavior, including attention-seeking and dramatic behavior to gain approval or admiration from others, is a hallmark feature of histrionic personality disorder.
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