2024 PN NCLEX Questions Nursing Practice Question
While taking the vital signs of a pregnant client admitted to the labor unit, a nurse notes a temperature of 100.6°F, pulse rate of 100 beats/min, and respirations of 24 breaths/min. What is the most appropriate nursing action based on these findings?
Correct Answer: A
Rationale: In this scenario, a temperature of 100.6°F, pulse rate of 100 beats/min, and respirations of 24 breaths/min indicate potential signs of infection or other complications in a pregnant client. Notifying the registered nurse is essential for prompt assessment and intervention, as these vital signs may require immediate medical attention.
Option B, documenting the findings, is important but should follow notifying the RN, as immediate action is prioritized. Option C, rechecking vital signs in 1 hour, is not appropriate when abnormal findings are present; timely intervention is crucial. Option D, while important for comprehensive assessment, should occur after alerting the RN to address potential risks effectively.