The nurse performs a vaginal examination to determine labor progress. She notes that the FHR, as indicated on EFM, rises approximately 30 beats/minute above baseline for about 60 seconds. The nurse recognizes that:
a. This is a normal response of the fetus to the vaginal examination and requires documentation only.
b. This is an early sign of fetal infection and should be reported to the health care provider.
c. The laboring woman must be getting a fever to cause the FHR to rise like that.
d. This is an indication that the fetus may have a nuchal cord.
ANS: A
Accelerations are brief, temporary increases in fetal heart rate associated with fetal movement, vaginal examinations, uterine contractions, fundal pressure, and breech presentations. Accelerations are a reassuring FHR pattern and a sign of fetal well-being.
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A newly hired group of graduate practical/vocational nurses are attending orientation at a long-term care facility. What information will be included regarding considerations of mobility and the older adult? (Select all that apply.)
a. The skin of older adults is more fragile and susceptible to injury. b. Always support older adults under the soft tissue when moving them in bed. c. Weakness and hypertension are common signs and symptoms noted in an older adult on bed rest. d. Aging tends to result in loss of flexibility and joint mobility. e. Older adults sometimes become fearful when hydraulic lifts are used for transfers.
When giving a tubal medication, the nurse should flush the tubing with ___ to ___ mL of water
ANS:
A school-age child, a member of a family with a mother, father, and toddler, is hospitalized. The father is employed outside of the home, and the mother stays at home with the other child
The mother is challenged with supporting both children at this time. What should the nurse suggest to the mother? A) Place the toddler in day care. B) Suggest the father take time off to help. C) Ask extended family members to help out during this time. D) Visit with the patient after the father comes home from work.
The need for forceps has been determined. The patient's cervix is dilated to 10 cm, and the fetus is at +2 station. What category of forceps application would the nurse anticipate?
1. Input 2. Low 3. Mid 4. Outlet