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

Exhibits

Click to highlight the findings that indicate the interventions have been effective. To deselect a finding, click on the finding again.

Nurses' Notes

2230:

Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min with moderate variability. Accelerations present, no decelerations noted.

Vital Signs

2230:

Temperature 38° C (100.4° F)

Heart rate 88/min

Respiratory rate 16/min

Blood pressure 122/80 mm Hg

Oxygen saturation 98% on room air

A.

Client rates pain with contractions as a 3 on a scale of 0 to 10

B.

FHR 150/min with moderate variability. Accelerations present, no decelerations noted

C.

Heart rate 88/min

D.

Respiratory rate 16/min

E.

Blood pressure 122/80 mm Hg

F.

Oxygen saturation 98% on room air

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

  • Heart rate decreased from 104/min to 88/min, indicating improved hemodynamic stability.
  • Respiratory rate decreased from 20/min to 16/min, suggesting relaxation and reduced distress.
  • Blood pressure slightly decreased from 132/84 mm Hg to 122/80 mm Hg, indicating improved comfort and reduced pain-related stress response.
  • Pain level decreased to 3/10 after epidural placement, demonstrating effective pain management.
  • FHR 150/min with moderate variability and accelerations present, no decelerations, indicating fetal well-being.


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Related Questions

Correct Answer is A

Explanation

A. A child with cystic fibrosis and difficulty clearing secretions is the priority because airway clearance is critical in cystic fibrosis. Mucus buildup can lead to respiratory distress and infection, requiring immediate intervention.
B. A child with an atrial septal defect and a heart rate of 120/min is not the priority because a heart rate of 120/min is within the expected range for a 3-year-old and does not indicate immediate distress.
C. A child with type 1 diabetes and a blood sugar of 150 mg/dL is not the priority because this blood glucose level is slightly elevated but not critical.
D. A child with diarrhea and abdominal pain requires assessment, but dehydration or electrolyte imbalance develops over time. Airway issues take priority over gastrointestinal symptoms.

Correct Answer is B

Explanation

A. Wire cutters. This is incorrect because wire cutters are used for clients with wired jaws in case of an emergency but are not needed for chest tube management.
B. Padded clamp. This is correct because a padded clamp is necessary in case the chest tube needs to be momentarily clamped for troubleshooting air leaks or before removal.
C. Montgomery straps. This is incorrect because Montgomery straps are used to secure frequent dressing changes, such as for abdominal wounds, and are not relevant to chest tube management.
D. Tracheostomy tray. This is incorrect because a tracheostomy tray is used for clients at risk for airway obstruction, which is not a routine need following a thoracotomy with chest tube placement.

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