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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Acetaminophen is a suitable option for pain relief in clients with a history of peptic ulcer because it does not typically irritate the gastric mucosa or increase the risk of gastrointestinal bleeding.
B. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastric ulceration and bleeding, especially in clients with a history of peptic ulcer.
C. Aspirin is also an NSAID and can increase the risk of gastric ulceration and bleeding, particularly in individuals with a history of peptic ulcer.
D. Ketorolac is an NSAID with a high risk of gastrointestinal side effects, including peptic ulceration and bleeding, and should be avoided in clients with a history of peptic ulcer.
Correct Answer is C
Explanation
A. Prealbumin levels are often used as a marker of nutritional status and can indicate protein deficiency. A low prealbumin level may suggest malnutrition or inadequate protein intake. However, the prealbumin level of 25 mg/dL is within the normal range (normal range typically 15-35 mg/dL), so it does not require immediate reporting to the provider.
B. The client's temperature of 37.6°C (99.7°F) is slightly elevated but is not indicative of a fever (typically defined as ≥38°C or 100.4°F). This finding may suggest a mild increase in body temperature, which could be related to various factors such as dehydration, infection, or environmental factors. Since it's only slightly elevated and within a
borderline range, it may not require immediate reporting unless other concerning symptoms are present.
C. Urine specific gravity measures the concentration of solutes in the urine and can indicate hydration status. A specific gravity of 1.035 is considered high and may suggest concentrated urine, which could be a sign of dehydration or renal dysfunction. Therefore, this finding should be reported to the provider for further evaluation.
D. Hypoactive bowel sounds indicate decreased or absent bowel motility and can be a sign of gastrointestinal dysfunction, such as ileus or obstruction. While it's important to monitor bowel sounds and report any significant changes to the provider, hypoactive bowel sounds alone may not always require immediate reporting unless other concerning symptoms are present.
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