The practical nurse (PN) is obtaining fetal heart rates on four antepartum clients in their third trimester of pregnancy. Which fetal heart rate should be reported to the registered nurse (RN) immediately?
152
118
180
136
The Correct Answer is C
A. 152: A fetal heart rate (FHR) of 152 beats per minute is within the normal range for a third-trimester fetus (110–160 bpm) and does not require immediate intervention.
B. 118: A FHR of 118 bpm is slightly on the lower end of the normal range but still considered acceptable for a healthy fetus, though monitoring may continue.
C. 180: A FHR of 180 bpm exceeds the normal range and may indicate fetal tachycardia, which can result from maternal fever, infection, hypoxia, or fetal distress. This requires immediate reporting to the RN for assessment and potential intervention.
D. 136: A FHR of 136 bpm falls within the normal range and does not necessitate urgent reporting, though routine monitoring should continue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Quinapril: Quinapril is an angiotensin-converting enzyme (ACE) inhibitor. A persistent dry cough is a well-known side effect due to accumulation of bradykinin in the respiratory tract. Clients should be informed that the cough may resolve after discontinuation or switching to another antihypertensive class.
B. Spironolactone: Spironolactone is a potassium-sparing diuretic and does not commonly cause a dry cough. Its primary side effects include hyperkalemia, gynecomastia, and menstrual irregularities rather than respiratory symptoms.
C. Losartan: Losartan is an angiotensin II receptor blocker (ARB) and is less likely to cause a cough. It is often used as an alternative for clients who develop a cough with ACE inhibitors.
D. Clonidine: Clonidine is an alpha-2 adrenergic agonist used for hypertension. Common side effects include sedation, dry mouth, and hypotension, but it does not typically produce a persistent dry cough.
Correct Answer is C
Explanation
A. On the same side as the affected extremity: Placing the cane on the affected side reduces stability because the weaker side does not provide sufficient support. This increases the risk of falls and improper gait.
B. Approximately one foot away from the body to stabilize balance: Holding the cane too far from the body can compromise balance and coordination. Proper cane placement should maintain stability close to the body while allowing natural movement.
C. On the opposite side of the affected extremity: The cane should be held on the side opposite the weaker or affected limb. This provides optimal support and balance during ambulation, allowing the client to bear weight safely while stepping forward with the affected leg.
D. In front of the body to lean on while stepping forward: Leaning on the cane excessively shifts weight forward and can destabilize the client. The cane is intended to provide lateral support rather than function as a crutch for leaning.
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