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A nurse in an antepartum unit is caring for a client.

Exhibits
Select the 2 findings that require immediate follow-up.

A.

Blood pressure

B.

Fetal heart rate

C.

Fetal station

D.

Characteristics of amniotic fluid

E.

Duration of contraction

Answer and Explanation

Correct Answer : B,D

A. Blood pressure: The client’s BP is 128/84 mm Hg, which is within the normal range. Although the client has chronic hypertension, this BP reading does not indicate an immediate concern.

B. Fetal heart rate: The fetal heart rate (FHR) is 165/min, which is tachycardia (normal FHR range is 110–160/min). Fetal tachycardia can indicate infection, maternal fever, fetal distress, or hypoxia and requires immediate follow-up.

C. Fetal station: The station is 0, which means the presenting part is at the level of the ischial spines. This is normal for a laboring client at 4 cm dilation and does not require immediate intervention.

D. Characteristics of amniotic fluid: The fluid is green, indicating the presence of meconium-stained amniotic fluid, which suggests fetal distress or hypoxia. This requires immediate follow-up, as the baby is at risk for meconium aspiration syndrome.

E. Duration of contraction: The contraction lasted 40 seconds, which is within the normal range (30–90 seconds). This is not an immediate concern.


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Related Questions

Correct Answer is B

Explanation

A. "Store unused patches in the refrigerator." Scopolamine patches should be stored at room temperature, not in the refrigerator.
B. "Apply the patch prior to traveling." The patch should be applied at least four hours before travel to allow time for absorption and effectiveness.
C. "Place the patch on your upper arm." The patch should be applied behind the ear, not on the upper arm, for optimal absorption.
D. "Replace a dislodged patch onto the same location." A new patch should be applied to a different area to prevent skin irritation.

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

Explanation

The nurse should prepare to administer naloxone and oxygen by face mask 10 L/min.

Rationale:

  • Naloxone is used to reverse opioid-induced respiratory depression, which is a potential risk during moderate sedation.
  • Oxygen by face mask 10 L/min is necessary to maintain adequate oxygenation during and after sedation, as respiratory depression can occur.
  • Acetaminophen is not used for immediate management of sedation-related complications.
  • An additional dose of fentanyl or propofol would deepen sedation, not manage its complications.
  • Propranolol is a beta-blocker that is not indicated in this situation.

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