The nurse observes the following data on an electronic fetal ...

[urbanoutfitters]

The nurse observes the following data on an electronic fetal monitor attached to a client in the active phase of the first stage of labor: fetal heart rate baseline, 125 to 140 bpm, three accelerations over the course of 20 minutes, moderate variability.
 
  What is the priority action based on these findings?
 
  a. Document the findings.
  b. Contact the health care provider.
  c. Increase the rate of the existing IV to 200 mL/hr as per the standing prescription.
  d. Place oxygen via a rebreather mask at 10 L/min as per the standing prescription.

Question 2

A child is in the intensive care unit after a motor vehicle collision. The child has numerous fractures and is in pain that is rated 9 or 10 on a 10-point scale. In planning care, the nurse recognizes that the indicated action is which?
 
  a. Give only an opioid analgesic at this time.
  b. Increase dosage of analgesic until the child is adequately sedated.
  c. Plan a preventive schedule of pain medication around the clock.
  d. Give the child a clock and explain when she or he can have pain medications.

[jaymee143]

Answer to Question 1

ANS: A
The findings are all within normal limits for the laboring client. Accelerations are usually a reassuring sign. Normal fetal heart rate is 110 to 160 bpm and of moderate variability; amplitude range of 6 to 25 bpm is desirable. No intervention is required because the pattern suggests that the fetus has adequate reserves to tolerate intrapartum stressors.

Answer to Question 2

ANS: C
For severe postoperative pain, a preventive around the clock (ATC) schedule is necessary to prevent decreased plasma levels of medications. The opioid analgesic will help for the present, but it is not an effective strategy. Increasing the dosage requires an order. The nurse should give the drug on a regular schedule and evaluate the effectiveness. Using a clock is counterproductive because it focuses the child's attention on how long he or she will need to wait for pain relief.