A nurse in an antepartum unit is caring for a client.
Blood pressure
Fetal heart rate
Fetal station
Characteristics of amniotic fluid
Duration of contraction
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hearing difficulties can be a challenge but do not necessarily indicate social isolation unless they lead to withdrawal from activities.
B. Babysitting twice a month still allows for social interaction and does not suggest isolation.
C. Not attending church due to a lost hearing aid suggests withdrawal from social activities, which increases the risk of social isolation.
D. Having a family member assist with grocery shopping indicates some level of social interaction and support, reducing the risk of isolation.
Correct Answer is C
Explanation
A. Stimulants should not be administered to clients with acute alcohol toxicity, as they can increase agitation and cardiovascular stress.
B. Diuretics are not used for alcohol toxicity because they do not effectively eliminate alcohol and may contribute to dehydration.
C. Measuring urine specific gravity helps assess hydration status and kidney function, which can be affected by acute alcohol toxicity.
D. An NG tube is not routinely indicated unless the client is at risk for aspiration or requires gastric lavage due to severe intoxication.
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