The laboring client's fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction
What nursing action is best? 1. Document the fetal heart rate.
2. Apply oxygen via mask at 10 liters.
3. Prepare for imminent delivery.
4. Assist the client into Fowler's position.
1
Explanation: 1. The described fetal heart rate has a normal baseline; the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary.
You might also like to view...
A nurse is applying a 5% permethrin lotion to a toddler with scabies. Which of the following describes the best way to apply this lotion?
1. Apply the lotion to the scalp only. 2. Apply the lotion over the entire body from the chin down, as well as on the scalp and forehead. 3. Apply the lotion only on the areas with evidence of scabies activity. 4. Apply the lotion only to the hands.
A client who has been seen responding to auditory hallucinations earlier in the morning approaches
the nurse and shakes his fist, saying "Back off, bitch!" and then goes into the day room. The nurse follows the client into the day room. The nurse should a. move to a position that allows the client to be closest to the door. b. make sure physical space is present between herself and the client. c. position herself within an arm's length of the client. d. sit down in a chair near the client.
The patient has just had a tracheostomy tube placed and is expectorating copious amounts of sputum that he coughs forcefully from his tracheostomy tube
The patient also is suspected of having methicillin-resistant Staphylococcus aureus (MRSA) in his sputum. The nurse is preparing to suction the patient to clear his airway. Which of the following will the nurse need to wear if following standard precautions? (Select all that apply.) a. Mask b. Goggles c. Gown d. Sterile gloves
A nurse is asked to wash the hair of a patient who has a spinal cord injury. Which of the following is a guideline that the nurse should follow when performing this procedure?
A) Use extra padding on the shampoo board before placing it under the patient's head. B) Only use dry shampoo on a patient with a spinal cord injury. C) Place a protective pad under the head of the patient and divide the hair into four sections to be washed individually. D) Use a makeshift protection area consisting of a protective pad and rolled towel to direct the water into the container.