The nurse is caring for a client in labor. Which assessment finding will the nurse report to the charge nurse immediately?
FHR baseline 125
Temperature 99.9°F
BP 142/90
Contractions lasting 45-60 seconds
The Correct Answer is D
A. A FHR baseline of 125 is within the normal range for a fetal heart rate.
B. A temperature of 99.9°F is a mild elevation and may not be an immediate concern.
C. Blood pressure of 142/90 may be elevated but may not require immediate action unless associated with other concerning symptoms.
D. Contractions lasting 45-60 seconds are prolonged and may lead to decreased fetal oxygenation. This finding should be reported immediately to the charge nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Changing the client's position, especially if there's a cord compression causing variable decelerations, is a priority intervention to alleviate the decelerations.
B. Informing the primary care provider is important, but immediate action to address the decelerations should be taken first.
C. Vaginal examination is not the immediate priority when variable decelerations are observed; interventions to improve fetal oxygenation are more critical.
D. Continuous monitoring is essential, but addressing the cause of the variable decelerations by changing the client's position is the immediate action.
Correct Answer is B
Explanation
A. Client 4, who delivered 8 hours ago, having a fundus at the umbilicus is within the expected range for a client at this stage postpartum.
B. Client 2, two days postpartum with a fundus 2 cm above the umbilicus, is suggestive of uterine subinvolution, as the fundus should be descending, not rising, after delivery.
C. Client 1, three days postpartum with a fundus 3 cm below the umbilicus, is within the expected range for the postpartum period.
D. Client 3, one day postpartum with a fundus 1 cm below the umbilicus, is within the expected range for the postpartum period.
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