A nurse is caring for a male client who has a spinal cord injury.
Which of the following techniques should the nurse use when providing perineal care?

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.

Choice A rationale:

Providing a verbal report of the client's condition to the paramedic performing the transfer violates the client's confidentiality. Protected health information should not be disclosed verbally to individuals who do not have a need to know. Confidentiality must be maintained during all stages of care, including transfers.

Choice B rationale:

Faxing the client's name and identifiable information to the rehabilitation facility is not a secure method of transmitting sensitive health information. Faxed documents can be intercepted, compromising the client's confidentiality. Secure electronic methods or encrypted communication should be used for transmitting such information.

Choice C rationale:

Emailing the client's health information to the facility in an unencrypted file is also insecure and violates the client's confidentiality. Unencrypted emails can be intercepted and read by unauthorized individuals. Protected health information should be transmitted using secure, encrypted methods to maintain confidentiality.

Choice D rationale:

Discussing the client's response to the transfer with another staff nurse is inappropriate and breaches confidentiality. Sharing patient information, even within the healthcare team, should only be done on a need-to-know basis and in a secure, private setting.