A nurse is caring for a 34-year-old female client in the labor and delivery unit.
The nurse reviews the findings for the client. Which findings are concerning and require intervention? Select All That Apply)
Blood pressure of 170/98 mm Hg
Pain rating of 5 out of 10 with each contraction
Variable decelerations lasting 20 seconds
Fetal heart rate of 142 beats/minute with accelerations
Deep tendon reflexes absent
Temperature of 98.6° F (37° C)
Correct Answer : A,C,E
Choice A rationale: A blood pressure of 170/98 mm Hg is significantly elevated and concerning during pregnancy. This may indicate preeclampsia, which requires immediate intervention to prevent complications for both the mother and the fetus.
Choice B rationale: A pain rating of 5 out of 10 with each contraction is common during labor and does not necessarily require intervention unless the pain is unmanageable or the client requests additional pain relief measures.
Choice C rationale: Variable decelerations lasting 20 seconds can indicate cord compression or other issues affecting fetal oxygenation. Continuous monitoring and possible interventions are required to ensure fetal well-being.
Choice D rationale: A fetal heart rate of 142 beats/minute with accelerations is a reassuring sign of fetal well-being. No immediate intervention is needed for this finding.
Choice E rationale: Absent deep tendon reflexes are a concerning finding, especially with the administration of magnesium sulfate. This can indicate magnesium toxicity, which requires prompt intervention to adjust the medication dosage and prevent adverse effects.
Choice F rationale: A temperature of 98.6° F (37° C) is within normal limits and does not require intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Drinking water is not necessary before a triple screen analysis. This test does not require a full bladder.
Choice B rationale
The left lateral tilt position is typically used to prevent supine hypotensive syndrome in pregnant women during ultrasounds, not for a blood draw.
Choice C rationale
A triple screen analysis involves drawing blood from the mother to test for specific markers that indicate the risk of certain fetal abnormalities. Blood sampling is necessary for the analysis.
Choice D rationale
Applying an external fetal monitor is unrelated to a triple screen analysis, which focuses on maternal blood markers rather than fetal heart rate monitoring.
Correct Answer is ["50"]
Explanation
Step 1 is (2 grams/hour ÷ 20 grams) × 500 mL.
Step 2 is (2 ÷ 20) × 500.
Step 3 is 0.1 × 500. The final calculated answer is 50 mL/hour.
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