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 C
Explanation
A. Placing a newborn in a forward-facing car seat is unsafe and not recommended due to the risk of injury in case of a crash.
B. Turning the baby's car seat around at 15 pounds is too early. Rear-facing car seats are recommended until the child reaches the weight or height limit set by the manufacturer.
C. Positioning the baby at a 45-degree angle in the car seat helps prevent airway obstruction and allows for proper breathing and spinal alignment.
D. Placing a baby in the front seat, even with the airbag turned off, is not recommended due to the risk of injury from airbag deployment.
Correct Answer is D
Explanation
A: Alternative communication methods are more applicable to clients with severe speech or cognitive impairments, which are not universally present in multiple sclerosis.
B: Using clock numbers to describe food placement is typically recommended for visually impaired clients, not specifically for those with multiple sclerosis.
C: Touching the client's arm before speaking is a technique used for clients with hearing impairments.
D: Multiple sclerosis can cause fine motor skill impairment and muscle weakness. Providing large-handled utensils can help maintain independence in eating by making it easier to grip and use utensils.
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