A nurse is assessing a client who is in active labor.
Which of the following findings should the nurse report to the provider?
Early decelerations in the FHR.
Contractions lasting 80 seconds.
FHR baseline 170/min.
Temperature 37.4° C (99.3° F).
The Correct Answer is C
The correct answer is C. FHR baseline 170/min. This is because a normal FHR baseline is between 110 and 160 bpm, and anything above or below this range indicates fetal distress and should be reported to the provider. A FHR baseline of 170/min could indicate fetal tachycardia, which could be caused by maternal fever, infection, dehydration, fetal anemia, or fetal hypoxia.
Choice A is wrong because early decelerations in the FHR are normal and benign, and indicate head compression during contractions.
They do not require any intervention or reporting.
Choice B is wrong because contractions lasting 80 seconds are within the normal range for active labor, which is 40 to 90 seconds per contraction.
They do not indicate any complication or abnormality.
Choice D is wrong because a temperature of 37.4° C (99.3° F) is slightly elevated but not considered a fever. A fever is defined as a temperature of 38° C (100.4° F) or higher.
A mild increase in temperature could be due to dehydration, exertion, or environmental factors, and does not necessarily indicate infection or inflammation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B.
Choice A reason: Atrial fibrillation is characterized by a rapid, irregular heartbeat and an absence of distinct P waves on the ECG, which is not indicated by the information provided.
Choice B reason: First-degree AV block is indicated by a prolonged PR interval without affecting the overall heart rate, aligning with the client’s PR interval of 0.24 seconds.
Choice C reason: Premature ventricular contraction would show an abnormal QRS complex on the ECG, which is not mentioned in the scenario.
Choice D reason: Sinus bradycardia is defined by a heart rate less than 60 bpm, which does not apply here as the client’s heart rate is 69/min, within the normal range of 60-100 bpm.
Correct Answer is A
Explanation
When updating protocols for the use of belt restraints, the nurse manager should include the following guideline:
A) Document the client’s condition every 15 min
Frequent documentation of the client's condition and the need for restraint is essential to monitor their well-being and ensure that restraints are used only when necessary. The other options are not recommended:
B) Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used when there is an immediate risk to the patient or others, and obtaining a PRN prescription for restraints is generally not standard practice.
C) Attaching the restraint to the bed's side rails is not recommended because restraints should be used as a last resort, and there are specific guidelines for restraint application to ensure patient safety.
D) Removing the client's restraint every is not appropriate either. Restraints should only be removed when the client's condition improves, and alternatives to restraint have been explored, or when it's deemed necessary for the patient's safety and well-being following established protocols and guidelines. The option seems incomplete and does not specify the appropriate time frame for removal.
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