A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
Temperature 37.4° C (99.3° F)
Early decelerations in the FHR
Contractions lasting 80 seconds
FHR baseline 170/min
The Correct Answer is D
A. Temperature 37.4° C (99.3° F): This is a mild elevation and within normal limits for a laboring client. Slight temperature increases can occur due to physical exertion and are not typically concerning.
B. Early decelerations in the FHR: Early decelerations are usually benign and mirror uterine contractions, reflecting fetal head compression. They are not an indication for immediate intervention.
C. Contractions lasting 80 seconds: Normal uterine contractions in active labor typically last 45–80 seconds. While the upper limit of 80 seconds is noted, this alone does not require urgent reporting if the contraction pattern and fetal response remain reassuring.
D. FHR baseline 170/min: A baseline fetal heart rate above 160/min indicates fetal tachycardia, which can result from maternal infection, fetal hypoxia, or other complications. This finding requires prompt notification of the provider for further evaluation and potential intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Apply the largest cuff available: Using an inappropriately large cuff can lead to inaccurate blood pressure readings, often underestimating the true values. The cuff size should be proportional to the client’s arm circumference, not simply the largest available.
B. Use the palpatory method to determine blood pressure: When Korotkoff sounds are difficult to auscultate, the nurse can use the palpatory method to estimate systolic pressure. This involves palpating the radial or brachial pulse while inflating the cuff and noting when the pulse disappears and reappears, providing a reliable alternative for measuring blood pressure.
C. Place the arm above the level of the client's heart: Positioning the arm above heart level can artificially lower the measured blood pressure due to hydrostatic effects. Proper technique requires the arm to be at heart level for accurate assessment.
D. Deflate the cuff quickly: Rapid deflation can cause missed Korotkoff sounds and inaccurate readings. The cuff should be deflated slowly, at a rate of 2–3 mm Hg per second, to ensure correct auscultation of both systolic and diastolic pressures.
Correct Answer is D
Explanation
A. Platelet count: Platelet count evaluates clotting potential related to platelet number, but it is not used to monitor or dose warfarin therapy. Warfarin affects vitamin K–dependent clotting factors rather than platelets.
B. Fibrinogen level: Fibrinogen is a plasma protein essential for clot formation, but it is not used to guide warfarin therapy. Fibrinogen testing is more relevant in bleeding disorders or DIC, not routine anticoagulation management.
C. aPTT: Activated partial thromboplastin time (aPTT) is primarily used to monitor heparin therapy. Warfarin does not significantly alter aPTT, so this test is not appropriate for warfarin dose adjustments.
D. INR: The international normalized ratio (INR) standardizes prothrombin time and is the primary laboratory test used to monitor warfarin therapy. Reporting the INR allows the provider to safely adjust the daily warfarin dose to maintain therapeutic anticoagulation.
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