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)

Answer and Explanation

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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Correct Answer is C

Explanation

A. While metronidazole is an antimicrobial medication, it does not pose a significant biohazard risk, and standard precautions for medication spills would suffice.

B. Ampicillin sodium is an antibiotic medication and does not pose a significant biohazard risk, and standard precautions for medication spills would suffice.
C. Doxorubicin hydrochloride is a cytotoxic chemotherapy medication that poses a significant biohazard risk due to its potential carcinogenic and mutagenic properties. Specific facility procedures for handling cytotoxic spills should be followed.
D. Phenytoin is an antiepileptic medication and does not pose a significant biohazard risk, and standard precautions for medication spills would suffice.

A. Maintain eye contact with the newborn during feedings. B. Minimize noise in the newborn's environment. C. Administer naloxone to the newborn. D. Swaddle the newborn with his legs extended.

Correct Answer is B

Explanation

A. While maintaining eye contact during feedings can foster bonding and comfort, it is not specifically beneficial for managing symptoms of neonatal abstinence syndrome (NAS).
B. Minimizing noise in the newborn's environment is crucial for a baby with NAS. These infants often have increased sensitivity to stimulation and can become easily agitated. A quiet, calming environment can help soothe them.
C. Administering naloxone to a newborn with NAS is not recommended. Naloxone is an opioid antagonist and, while it can reverse opioid effects acutely, it is not a treatment for the withdrawal symptoms associated with NAS.
D. Swaddling the newborn is beneficial, but the legs should not be extended.

Swaddling should allow for some movement of the legs and hips to prevent the development of hip dysplasia. Swaddling in a way that allows the legs to bend and move is generally recommended.

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A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?

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Correct Answer is C

Explanation

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