A nurse is caring for a client who is in active labor. The nurse should notify the provider for which of the following findings?
Moderate variability in the FHR
Prolonged decelerations
Baseline FHR 115/min
Three uterine contractions within 10 min
The Correct Answer is B
A. Moderate variability in the FHR: Incorrect. Moderate variability (6-25 bpm) is a reassuring sign of fetal well-being.
B. Prolonged decelerations: Prolonged decelerations, defined as a decrease in fetal heart rate (FHR) of at least 15 beats per minute lasting 2 to 10 minutes, indicate potential fetal hypoxia or distress and require immediate notification of the provider.
C. Baseline FHR 115/min: Incorrect. A baseline FHR of 115/min is within the normal range of 110-160 bpm.
D. Three uterine contractions within 10 min: Incorrect. This contraction pattern is within the normal range for active labor (normal is 2-5 contractions in 10 minutes).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A: Disconnecting the suction to the OG tube while holding the baby is not advisable, especially if the baby is on suction due to abdominal concerns such as NEC. The OG tube is used to decompress the stomach, and disconnecting it without proper instructions can worsen the condition. Therefore, this statement indicates a lack of understanding.
B: While genetic factors may influence some neonatal conditions, NEC is not a genetic disorder. The statement about passing a gene to the baby and potentially to the next child is not accurate in this context.
C: Necrotizing enterocolitis (NEC) is a severe gastrointestinal emergency commonly seen in preterm neonates, and it can lead to bowel perforation. In cases of extensive bowel damage or perforation, surgical intervention may be required, including the possibility of an ostomy. This is a correct statement that reflects the understanding of the potential treatment plan for the neonate.
D: NEC typically involves the inability to tolerate feedings, and in such cases, feeding is often withheld temporarily. The baby would not need high-calorie formula in this situation; instead, the focus would be on managing NEC, potentially with IV nutrition or parenteral nutrition (TPN), and addressing the need for surgical intervention.
Correct Answer is A
Explanation
A. Protect the IV bag from exposure to light: Nitroprusside is light-sensitive and degrades when exposed to light, reducing its potency and effectiveness. It must be protected with an opaque covering.
B. Keep calcium gluconate at the client’s bedside: Incorrect. Calcium gluconate is used to treat hyperkalemia or calcium imbalances, not for nitroprusside administration.
C. Attach an inline filter to the IV tubing: Incorrect. An inline filter is not typically required for nitroprusside.
D. Monitor blood pressure every 2 hr: Incorrect. Continuous or frequent monitoring (every 5-15 minutes) is necessary due to the rapid effects of nitroprusside on blood pressure.
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