Perfusion

A client is 41 weeks gestation and is admitted to the hospital in true labor. She has an external fetal monitor in place. What does the nurse recognize as a reassuring fetal heart rate (FHR) pattern? spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds late decelerations that occur with over 50% of contractions repetitive (at least 3) uncomplicated variable decelerations late decelerations with minimal variability

An increase of 15 bpm of the FHR for the duration of at least 15 seconds is a normal, reassuring FHR pattern. Late decelerations are periodic uniform changes in the FHR that are associated with uterine contractions. Multiple late decelerations may be a result of uteroplacental insufficiency or compromised uteroplacental perfusion requiring an intervention in attempts to enhance circulation and fetal oxygenation. Repetitive variable decelerations may be associated with umbilical cord compression and may require changes in maternal positioning to relieve the cord compression.

A 15-year-old client is 4 cm dilated and 100% effaced and is in active labor with her first baby. The nurse contacts the physician to communicate the findings of fetal heart rate decelerations, thick meconium in the amniotic fluid, and low fetal scalp pH results. What is the most appropriate nursing action at this time? Encourage the client to get into the right lateral position. Increase the oxygen to 7 L/min. Prepare the client for an assisted or cesarean birth. Contact the social worker to inform him/her of imminent birth.

Fetal heart decelerations, thick meconium, and low fetal scalp pH indicate severe fetal distress. Because the client is a primigravida and in early labor at 4 cm cervical dilatation, it is unlikely that the baby will tolerate further labor and a vaginal birth. It is prudent for the nurse to begin preparing the client for an assisted or operative birth. While changing maternal position and increasing oxygen availability may enhance placental perfusion and fetal oxygenation, these interventions do not meet the immediate fetal needs. There are no implications that a social worker needs to be involved in the care provided at this particular stage.

As an initial step in treating a client with angina, the health care provider (HCP) prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by: antispasmodic effects on the pericardium. causing an increased myocardial oxygen demand. vasodilation of peripheral vasculature. improved conductivity in the myocardium.

Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.

A client with cardiac disease gives birth. Afterward, the nurse assesses the client for signs and symptoms of cardiac decompensation. During the postpartum period, which assessment finding indicates a need for further investigation? diuresis uterine pain tachycardia weight loss

Tachycardia can indicate cardiac decompensation. Weight gain, not loss, may be a sign of heart failure. Diuresis and resulting weight loss are normal after giving birth. Uterine pain may result from the uterus contracting as it shrinks and isn't an immediate concern.

A transfusion of packed red blood cells has been prescribed for a 1-year-old with sickle cell anemia. The infant has a 25-gauge IV infusing dextrose with sodium and potassium. Using the situation, background, assessment, and recommendation (SBAR) method of communication, the nurse contacts the health care provider and makes which recommendation? starting a second IV with a 22-gauge catheter to infuse normal saline with the blood using the existing IV, but changing the fluids to normal saline for the transfusion replacing the IV with a 22-gauge catheter to infuse the prescribed fluids starting a second IV with a 25-gauge catheter to infuse normal saline with the transfusion

The best evidence indicates that a catheter as small as 27 gauge may safely be used for transfusion in children, but blood must be infused with normal saline, not dextrose. A 1-year-old should be able to maintain his or their blood glucose for the 2-hour duration of the infusion without the need for a second IV.

The healthcare provider orders digoxin for the client with congestive heart failure. What should the nurse include in the client's teaching concerning the administration of digoxin? Select all that apply. "Digoxin can cause swelling of the face, lips, or tongue." "Digoxin can cause seizures." "Digoxin can cause a decreased urinary output." "Digoxin can cause a fast, irregular heartbeat." "Digoxin can cause decreased respiratory rate."

The nurse should explain to the client that digoxin can cause allergic reactions, such as skin rash, itching or hives, swelling of the face, lips or tongue, changes in behavior, mood, or mental ability, changes in vision, confusion, a fast, irregular heartbeat, or feeling faint or lightheaded. Digoxin does not cause decreased respiratory rate, decreased urinary output, or seizures.

A nurse is caring for a client admitted to the telemetry unit 4 days post coronary artery bypass graft (CABG) surgery. Which elements should the nurse monitor? Select all that apply. electrocardiogram (EKG) level of consciousness BUN and serum creatinine visitors entering the client's room pain management

Atrial fibrillation is a common occurrence after CABG (coronary artery bypass graft) surgery. The nurse should monitor the EKG, assess for level of consciousness in order to prevent a possible stroke, and observe for signs of deep vein thrombosis (DVT) and pulmonary emboli (PE). Elevated BUN and creatinine indicate potential acute renal failure and should be reported. Monitoring for other incidence of postoperative complications including the chest incision for symptoms of infection, management of pain, and prevention of respiratory complications through the use of incentive spirometer is essential. There is no need to monitor visitors unless additional complications are present.