Which action should the nurse take?
Document the normal finding.
Notify the healthcare provider.
Schedule an ultrasound.
Obtain hematocrit level.
The Correct Answer is B
Choice A rationale
Documenting the finding without further action is inappropriate when faced with an abnormal FHR pattern. Immediate intervention is crucial to prevent potential fetal hypoxia or distress, necessitating a prompt response.
Choice B rationale
Notifying the healthcare provider is essential when encountering abnormal FHR patterns. Timely communication allows for appropriate interventions to be implemented, reducing the risk of adverse fetal outcomes and ensuring patient safety.
Choice C rationale
Scheduling an ultrasound is not the immediate priority when an abnormal FHR pattern is detected. Immediate clinical evaluation and interventions are necessary to address potential fetal distress or hypoxia.
Choice D rationale
Obtaining a hematocrit level is unrelated to the immediate management of abnormal FHR patterns. The priority is to address the fetal well-being and ensure adequate oxygenation through timely clinical interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","F","G"]
Explanation
Choice B rationale
Proteinuria indicates preeclampsia, which involves increased glomerular permeability due to endothelial damage. Normal protein in urine is <150 mg/day.
Choice F rationale
Hyperreflexia can be a sign of CNS irritability in preeclampsia, which can lead to seizures if untreated. Normal reflexes are 2+.
Choice G rationale
Assessing lung sounds is critical as pulmonary edema can develop in severe preeclampsia due to increased capillary permeability. Normal breath sounds are clear and equal bilaterally.
Choice D rationale
A vision test helps assess for visual disturbances due to cerebral edema or optic nerve involvement in preeclampsia. Normal visual acuity is 20/20.
Choice A rationale
Hemoglobin assessment could indicate anemia, but it does not specifically address preeclampsia symptoms. Normal hemoglobin is 12-16 g/dL for women.
Choice C rationale
Perineal assessment checks for infection or hematoma but is less likely to explain systemic symptoms like headache and dizziness.
Choice E rationale
Skin turgor assesses hydration status, but dehydration is less likely to explain severe headache, dizziness, and visual disturbances. Normal skin turgor is immediate recoil.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Evaluating fetal heart rate and contraction patterns is critical as magnesium sulfate can impact uterine activity and fetal well-being. Monitoring ensures timely intervention if abnormalities in fetal status or labor progression are detected.
Choice B rationale
Obtaining a prescription to repeat the hepatic panel is necessary to monitor liver function, especially if there is a suspicion of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count) which complicates severe preeclampsia.
Choice C rationale
Monitoring for evidence of seizure activity is crucial as the patient is receiving magnesium sulfate for eclampsia prophylaxis. Close observation helps in early detection and management of any seizure episodes, preventing complications.
Choice D rationale
Checking urinary output in an hourly urinometer is essential to assess renal function, as preeclampsia and magnesium sulfate can affect renal perfusion and output. Monitoring ensures timely intervention if there is a decline in output.
Choice E rationale
Inspecting the perineum for vaginal bleeding is less immediately relevant unless there is a concern for placental abruption or other obstetric complications. Focus on maternal systemic symptoms and fetal monitoring is more critical initially.
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