A nurse is caring for a client who is in active labor. The nurse should notify the provider for which of the following findings?
Moderate variability in the FHR
Prolonged decelerations
Baseline FHR 115/min
Three uterine contractions within 10 min
The Correct Answer is B
A. Moderate variability in the FHR: Incorrect. Moderate variability (6-25 bpm) is a reassuring sign of fetal well-being.
B. Prolonged decelerations: Prolonged decelerations, defined as a decrease in fetal heart rate (FHR) of at least 15 beats per minute lasting 2 to 10 minutes, indicate potential fetal hypoxia or distress and require immediate notification of the provider.
C. Baseline FHR 115/min: Incorrect. A baseline FHR of 115/min is within the normal range of 110-160 bpm.
D. Three uterine contractions within 10 min: Incorrect. This contraction pattern is within the normal range for active labor (normal is 2-5 contractions in 10 minutes).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Keep your feet together to provide a tight base of support": Incorrect. Keeping feet together reduces stability; a wide base of support is recommended.
B. "Keep objects away from your center of gravity while lifting": Incorrect. Objects should be kept close to the center of gravity to reduce strain.
C. "Bend at the waist when lifting objects from the floor": Incorrect. Bending at the knees, not the waist, is the correct technique to prevent back injury.
D. "Tighten abdominal muscles to improve balance": Tightening the abdominal muscles provides core stability and reduces the risk of injury when lifting.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"D"}
Explanation
- Lithium toxicity: The client's lithium level is significantly elevated at 2.5 mEq/L (normal range is 0.6 to 1.2 mEq/L), and symptoms such as blurred vision, increased urine output, and clonic jerking of the upper extremities are indicative of lithium toxicity2.
- Seizure activity: Lithium toxicity can lead to neurological symptoms, including seizures, which require close monitoring
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