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 A
Explanation
A. Tidaling in the water seal chamber indicates normal fluctuations in pressure as the client inhales and exhales, signifying that the system is functioning properly.
B. Absence of tidaling may indicate that the lung has fully re-expanded.
C. A loop of tubing below the system can cause drainage issues but does not cause tidaling.
D. Clots can partially obstruct the tubing but would not cause regular tidaling.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Sepsis: Preterm neonates are at increased risk for infections, including sepsis. Discontinuation of feedings, along with the other signs observed (such as abdominal distention, blood in stool, lethargy, and hypotonia), may suggest the onset of infection, which requires close monitoring.
Hypotension: Preterm neonates are also at risk for hypotension due to immature circulatory systems. The stress of gastrointestinal disturbances, such as abdominal distention and the potential for necrotizing enterocolitis (NEC), can result in decreased perfusion, contributing to hypotension.
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