The nurse is caring for a client in labor. Which assessment finding will the nurse report to the charge nurse immediately?
FHR baseline 125
Temperature 99.9°F
BP 142/90
Contractions lasting 45-60 seconds
The Correct Answer is D
A. A FHR baseline of 125 is within the normal range for a fetal heart rate.
B. A temperature of 99.9°F is a mild elevation and may not be an immediate concern.
C. Blood pressure of 142/90 may be elevated but may not require immediate action unless associated with other concerning symptoms.
D. Contractions lasting 45-60 seconds are prolonged and may lead to decreased fetal oxygenation. This finding should be reported immediately to the charge nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Early decelerations are generally considered benign and not an indication for a vaginal exam unless other concerning factors are present.
B. Promptly informing the primary care provider may not be necessary for early decelerations, which are often a normal response to head compression.
C. Continuous monitoring and observation of the client and fetal heart rate are appropriate for early decelerations, especially when the baseline is reassuring and there is moderate variability.
D. Repositioning the client to the left side is a general measure for optimizing fetal oxygenation, but it may not be the priority in the case of early decelerations, which are usually benign and
related to head compression.
Correct Answer is ["100"]
Explanation
To calculate the flow rate in mL/hr, we need to use the following formula:
Flow rate (mL/hr) = Dose (mU/min) x Volume (mL) / Concentration (units)
In this case, the dose is 2 mU/min, the volume is 1000 mL, and the concentration is 20 units. Plugging these values into the formula, we get:
Flow rate (mL/hr) = 2 x 1000 / 20 Flow rate (mL/hr) = 2000 / 20 Flow rate (mL/hr) = 100
Therefore, the flow rate in mL/hr is 100.
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