Which action should the nurse take?

Document the normal finding.

Notify the healthcare provider.

Schedule an ultrasound.

Obtain hematocrit level.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Documenting the finding without further action is inappropriate when faced with an abnormal FHR pattern. Immediate intervention is crucial to prevent potential fetal hypoxia or distress, necessitating a prompt response.

Choice B rationale

Notifying the healthcare provider is essential when encountering abnormal FHR patterns. Timely communication allows for appropriate interventions to be implemented, reducing the risk of adverse fetal outcomes and ensuring patient safety.

Choice C rationale

Scheduling an ultrasound is not the immediate priority when an abnormal FHR pattern is detected. Immediate clinical evaluation and interventions are necessary to address potential fetal distress or hypoxia.

Choice D rationale

Obtaining a hematocrit level is unrelated to the immediate management of abnormal FHR patterns. The priority is to address the fetal well-being and ensure adequate oxygenation through timely clinical interventions.

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Correct Answer is C

Explanation

Choice A rationale

Collecting a urine sample for dipstick analysis can identify urinary tract infections (UTIs) or other abnormalities. Dipstick tests detect leukocytes, nitrites, protein, and glucose, providing rapid results for initial screening of urinary issues.

Choice B rationale

Asking the client if she had sexual intercourse yesterday may help identify potential causes of urinary frequency, such as post-coital irritation. However, it does not directly address the irregular uterine contractions or possible infections.

Choice C rationale

Obtaining a midstream urine specimen for culture is crucial for diagnosing UTIs, which can cause urinary frequency and uterine irritability. Culturing urine identifies specific pathogens, guiding targeted antibiotic therapy to treat the infection.

Choice D rationale

Determining if she has a change in vaginal discharge can indicate infections or other conditions affecting the reproductive tract. However, it does not directly address the urinary frequency or irregular uterine contractions, making it less immediate.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"E"}

Explanation

Acidemia: Acidemia refers to an abnormal acidity in the blood (pH < 7.35). Prolonged abnormal FHR patterns can indicate insufficient oxygen delivery to the fetus, leading to anaerobic metabolism and the production of lactic acid, causing acidemia. The normal fetal pH is around 7.30-7.35.

Hypoxemia: Hypoxemia is a reduced level of oxygen in the blood. Abnormal FHR patterns may signal that the fetus is not receiving adequate oxygen, potentially due to cord compression, placental insufficiency, or other factors affecting oxygen transfer. Normal oxygen saturation for a fetus is generally around 30-70%.

Hypoxia: Hypoxia is a condition where there is insufficient oxygen available to meet the metabolic needs of the fetus. Abnormal FHR patterns can indicate ongoing or impending hypoxia, which can lead to severe fetal distress and compromise. It is crucial to monitor and address such conditions promptly.

Rationale for Incorrect Answers:

Hypoglycemia: Hypoglycemia refers to low blood glucose levels (typically < 45 mg/dL in newborns). Abnormal FHR patterns are not directly associated with changes in glucose metabolism. Rather, hypoglycemia in neonates is often related to maternal diabetes, prematurity, or other metabolic disturbances.

Meconium Stool: Meconium-stained amniotic fluid is a possible indicator of fetal distress but is not a direct result of abnormal FHR patterns. Meconium passage may be associated with post-term pregnancy, fetal hypoxia, or other factors, but the direct consequences of abnormal FHR patterns are more specifically related to oxygenation and acid-base status.

Maternal Hypotension: Maternal hypotension, or low blood pressure (typically < 90/60 mm Hg), is a maternal condition that can affect fetal well-being if severe and prolonged. However, it is not a direct result of abnormal FHR patterns. Instead, maternal hypotension can contribute to abnormal FHR by impairing uteroplacental perfusion.

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Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

During a routine prenatal visit, a client at 32-weeks gestation reports that urinary frequency has increased during the day as well as at night. The nurse determines the client is having irregular uterine contractions. Which action should the nurse implement?

Correct Answer is C

Explanation

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"E"}

Explanation

Assessment findings of a 4-hour-old newborn include murmur, irregular respiratory rate at 64 breaths/min, heart rate of 150 beats/min with soft murmur, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?

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