Nokea
A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Contractions lasting 80 seconds.
- B. Early decelerations in the PHR.
- C. Temperature 37.4° C (99 3* F).
- D. PHR baseline 170/min.
Correct Answer: D
Rationale: The correct answer is D: PHR baseline 170/min. A baseline fetal heart rate of 170/min is considered tachycardia and may indicate fetal distress, requiring immediate attention. This finding can be indicative of fetal hypoxia or other complications. The nurse should report this to the provider promptly for further evaluation and intervention.
Contractions lasting 80 seconds (choice A) are within the normal range for active labor and do not necessarily require immediate reporting.
Early decelerations in the PHR (choice B) are benign and typically not a cause for concern unless they are persistent or associated with other abnormal findings.
A temperature of 37.4°C (99.3°F) (choice C) is within normal limits and does not require immediate reporting unless it continues to rise significantly.
In summary, the correct answer is D because a baseline fetal heart rate of 170/min is abnormal and potentially indicative of fetal distress, requiring immediate provider notification.
You may also like to solve these questions
A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?
- A. Your baby needs an IV because she is not producing tears.
- B. Your baby needs an IV because her heart rate is decreased.
- C. Your baby needs an IV because she is breathing slower than normal.
- D. Your baby needs an IV because her fontanels are bulging.
Correct Answer: A
Rationale: The correct answer is A. Infants with severe dehydration may not produce tears due to lack of fluid. This indicates the need for IV fluid therapy to rehydrate the baby. Lack of tears is a sign of significant dehydration in infants.
Option B, decreased heart rate, is not a specific sign of dehydration in infants and not a direct indication for IV fluids. Option C, slow breathing, is also not a direct indication of dehydration, as infants may have varied respiratory rates for other reasons. Option D, bulging fontanels, can be a sign of increased intracranial pressure but is not a direct indication for IV fluids in this context.
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 105/64 mm Hg.
- B. Heart rate 98/min.
- C. Urine output of 280 mL within 8 hr.
- D. Urine negative for ketones.
Correct Answer: C
Rationale: The correct answer is C: Urine output of 280 mL within 8 hr. In hyperemesis gravidarum, decreased urine output can indicate dehydration, a serious complication. The nurse should report this finding to the provider to ensure prompt intervention. A: Blood pressure 105/64 mm Hg is within normal range for pregnancy. B: Heart rate 98/min may be slightly elevated but not concerning. D: Urine negative for ketones is expected with IV fluid replacement.
A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?
- A. "The nurse will carry your baby in their arms to the nursery for scheduled procedures."
- B. "We will document the relationship of visitors in your medical record."
- C. "It's okay for your baby to sleep in the bed with you while in the hospital."
- D. "Staff members who take care of your baby will be wearing a photo identification badge."
Correct Answer: D
Rationale: The correct answer is D. The nurse should inform the client that staff members caring for the newborn will be wearing a photo identification badge as a safety measure. This ensures that only authorized personnel are handling the baby, reducing the risk of abduction or unauthorized access. It also helps the client easily identify legitimate staff members.
Choice A is incorrect because it is not recommended for nurses to carry newborns to the nursery for procedures due to infection control policies. Choice B is irrelevant to promoting the security and safety of the newborn. Choice C is incorrect as bed-sharing with a newborn in the hospital setting is not safe due to the risk of suffocation and Sudden Infant Death Syndrome (SIDS).
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
- A. A newborn who is 26 hr old and has erythema toxicum on their face.
- B. A newborn who is 32 hr old and has not passed a meconium stool.
- C. A newborn who is 12 hr old and has pink-tinged urine.
- D. A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F).
Correct Answer: B
Rationale: The correct answer is B. A newborn who is 32 hr old and has not passed a meconium stool should be reported to the provider. Meconium should be passed within the first 24-48 hours of life, so the delay could indicate an obstruction or other issue. Choices A, C, and D are all within normal ranges for newborn assessments and do not require immediate reporting to the provider. E, F, and G are not provided as options.
A nurse is reviewing the provider's prescription in the adolescent's
medical chart.
Exhibit 1
History and Physical
Adolescent is sexually active with two current partners.
IUD in place
Reports not using condoms during sexual activity.
History of type 1 diabetes mellitus
The nurse is reviewing the provider's prescriptions in the adolescent's medical chart.Complete the following sentence by using the list of options. The nurse should first implement ---------------------- and ---------------------------------
- A. Providing education on medications
- B. Administering ceftriaxone
- C. Administering metronidazole and educating on condom use
Correct Answer: A,B
Rationale: The correct answer is A,B. First, providing education on medications is crucial to ensure the adolescent understands the prescribed treatment. This empowers them to adhere to the regimen, promoting better health outcomes. Second, administering ceftriaxone aligns with the provider's prescription and is a direct action the nurse must take to carry out the treatment plan. Choices C, D, E, F, and G are incorrect because administering metronidazole and educating on condom use (C) is not the immediate priority. Administering metronidazole is not mentioned in the provider's prescriptions, so it is not the first step. Choices D, E, F, and G are irrelevant and not related to the provider's prescriptions or the adolescent's care.