A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
Contractions lasting 80 seconds
Early decelerations in the FHR
FHR baseline 170/min
Temperature 37.4° C (99.3° F)
The Correct Answer is C
A. Contractions lasting 80 seconds, while prolonged, may occur in active labor and do not necessarily indicate a complication requiring immediate provider notification.
B. Early decelerations in the fetal heart rate are typically benign and are not typically concerning unless they are persistent or associated with other signs of fetal distress.
C. An FHR baseline of 170/min is above the normal range and may indicate fetal distress or other complications requiring further evaluation and possible intervention, necessitating prompt provider notification.
D. A temperature of 37.4°C (99.3°F) is within the normal range and does not typically require immediate provider notification unless accompanied by other concerning symptoms.
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Related Questions
Correct Answer is D
Explanation
A. This would involve irregular beats and potentially a visible compensatory pause, not a prolonged PR interval.
B. Atrial fibrillation features an irregularly irregular rhythm and no discernible PR intervals.
C. Defined by a heart rate less than 60/min with a normal rhythm and electrical pattern, which does not apply here given the normal rate and prolonged PR interval.
D. A first-degree atrioventricular (AV) block is characterized by a prolonged PR interval (greater than 0.20 seconds) in the presence of a normal heart rate and rhythm, which aligns with the client’s PR interval of 0.24 seconds and a heart rate of 69/min
Correct Answer is D
Explanation
A. While completing an incident report is important for addressing the medication error and implementing corrective actions, the immediate priority is to assess the client's condition for signs of bleeding, which could be life-threatening.
B. Monitoring aPTT levels is important to assess the client's response to heparin therapy, but it does not address the immediate risk of bleeding from the overdose.
C. Notifying the risk manager is essential for reporting the medication error and implementing strategies to prevent future occurrences, but the nurse's first action should be to assess the client's condition for any indications of bleeding.
D. Administering a high dose of heparin increases the risk of bleeding, so the nurse should first assess the client for any signs or symptoms of bleeding, such as unexplained bruising, hematuria, or hypotension, to ensure timely intervention and prevent complication.
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