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.
Three uterine contractions within 10 min.
Baseline FHR 115/min.
The Correct Answer is B
Choice A rationale:
Moderate variability in the FHR is a reassuring sign of fetal well-being, indicating a responsive fetal autonomic nervous system to normal physiologic stimuli. It is considered a normal finding in active labor, suggesting that the fetus is well-oxygenated and able to cope with contractions.
Choice B rationale:
Prolonged decelerations are concerning patterns on the fetal heart rate (FHR) monitor, indicating potential fetal distress. Prolonged decelerations are defined as lasting more than 2 minutes but less than 10 minutes. These decelerations can be caused by umbilical cord compression, placental insufficiency, or maternal hypotension. Prompt intervention is required, making this choice the correct answer.
Choice C rationale:
Three uterine contractions within 10 minutes, also known as a contraction stress test (CST), is a normal finding. It assesses the fetal response to stress and is used to evaluate the placental function and fetal well-being.
Choice D rationale:
A baseline FHR of 115/min is within the normal range (110-160 beats per minute) for a term fetus. It indicates a stable fetal heart rate, and there is no immediate need for intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
An altered level of consciousness is a common finding in clients with Alzheimer's disease. This may range from mild confusion to severe cognitive impairment. It is caused by the degeneration of brain cells and affects memory, thinking, and behavior.
Choice B rationale:
Rapid mood swings are not specific to Alzheimer's disease. While mood changes can occur, they are not typically characterized by rapid swings. Mood disturbances may include depression, apathy, or irritability, but these symptoms are not unique to Alzheimer's disease.
Choice C rationale:
Excessive motor activity is not a typical finding in clients with Alzheimer's disease. Instead, clients often experience a decline in motor skills and coordination as the disease progresses. Restlessness or agitation might occur, but excessive motor activity is not a characteristic feature.
Choice D rationale:
Failure to recognize familiar objects, people, or places is a common symptom of Alzheimer's disease. This is due to the damage and loss of nerve cells in the brain. As the disease advances, clients may have difficulty recognizing even close family members or their own reflection in the mirror.
Correct Answer is B
Explanation
The correct answer is choiceb. Obtain a CBC with differential.
Choice A rationale:
Drawing blood specimens for culture and sensitivity is not typically required before a cardiac catheterization unless there is a specific concern about infection.
Choice B rationale:
Obtaining a CBC with differential is important to assess the client’s overall health and detect any potential issues such as anemia or infection that could complicate the procedure.
Choice C rationale:
Transporting the client to radiology for a CT scan is not a standard pre-procedure task for cardiac catheterization. This might be necessary if there are specific indications, but it is not routine.
Choice D rationale:
Administering nitroglycerin 0.4 mg SL 30 minutes before the procedure is not a standard practice for preparing a client for cardiac catheterization.Nitroglycerin is typically used to manage chest pain or angina, not as a pre-procedure medication.
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