A nurse documents a paralyzed client's right heel ulcer as a ...

[tiara099]

A nurse documents a paralyzed client's right heel ulcer as a stage 3 pressure ulcer.
  Which describes a stage 3 pressure ulcer?
 
  A) Painless subcutaneous ulcer with foul-smelling discharge
  B) Painful and swollen shallow ulcer or blister
  C) Pressure-related changes of intact skin
  D) Small wound with extensive underlying damage

Question 2

A nurse is monitoring the fetal heart rate of a client. What signs of fetal distress on the fetal monitor should the nurse report immediately?
 
  A) Accelerations of 15 bpm
  B) Early decelerations
  C) Decreased variability
  D) Fetal heart rate above 100 bpm

[Hdosisshsbshs]

Answer to Question 1

A

Answer to Question 2

C
Feedback:
Decreased variability means little to no fluctuation in the FHR on an internal electronic monitor tracing, which is a danger sign. It may indicate an abnormality in the fetal nervous system. It might also indicate that the mother has taken or been given central nervous system depressants. Report this observation to the team leader for further evaluation. Accelerations are brief increases of the FHR of 15 bpm or more. It is a sign of a healthy fetus for the FHR to accelerate after movement or stimulation. Early decelerations are caused by vagal nerve stimulation resulting from pressure on the fetal head and are considered a normal response of the fetus to labor. A fetal heart rate above 100 bpm is normal. It should not fall below 100 bpm.

[tiara099]

Correct answers!

[Hdosisshsbshs]

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