A G1P0 client is in active labor at 39.1 weeks.
After receiving an epidural, the nurse performed a cervical check, noting the patient to be 5 cm dilated.
Approximately one hour later, the nurse observes a gradual decrease in the fetal heart rate with each contraction, noting the lowest point of the FHR aligns with the peak of the contraction.
What is the priority action at this time?
Reposition the patient and decrease the oxytocin.
Notify the provider to come for delivery.
Assess the patient for signs of perineal pressure or urge to push.
Increase the oxytocin to speed up the labor.
The Correct Answer is A
Choice A rationale
The observed fetal heart rate pattern, with a gradual decrease that mirrors the peak of the contraction, is indicative of a late deceleration. This pattern is a sign of uteroplacental insufficiency, where the fetus is not receiving adequate oxygen during contractions. Repositioning the patient and decreasing oxytocin are the priority actions to improve oxygenation and reduce uterine hyperstimulation.
Choice B rationale
Notifying the provider to come for delivery is not the immediate priority. While the provider needs to be informed, the nurse's first action is to intervene with measures to correct the issue and improve fetal oxygenation. The goal is to stabilize the fetal heart rate pattern before considering delivery options, which may not be necessary if the pattern resolves.
Choice C rationale
Assessing for perineal pressure or the urge to push is a routine part of labor assessment but is not the priority action for a late deceleration. This action is relevant for assessing for imminent birth, whereas the primary concern here is fetal well-being and correcting the underlying cause of the heart rate pattern.
Choice D rationale
Increasing oxytocin is contraindicated. Oxytocin stimulates uterine contractions, which in this case are causing the uteroplacental insufficiency. Increasing the dose would exacerbate the problem, further compromising fetal oxygenation and worsening the late decelerations. The appropriate action is to decrease or discontinue the oxytocin
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
Step 1 is: 300 ml ÷ 90 min × 60 min/hr.
Step 2 is: 3.333333333 ml/min × 60 min/hr.
Step 3 is: 200 ml/hr. Answer: 200
Correct Answer is C
Explanation
Choice A rationale
Amniotic fluid is primarily produced by the fetal kidneys, with the fetus excreting sterile urine into the amniotic sac. The fluid is constantly being produced and reabsorbed by the fetus swallowing it. The umbilical cord contains the blood vessels that connect the fetus to the placenta, not a producer of amniotic fluid.
Choice B rationale
The umbilical cord contains two arteries and one vein. The two arteries carry deoxygenated blood and waste products from the fetus to the placenta, while the single vein carries oxygenated and nutrient-rich blood from the placenta to the fetus. This is a common and important anatomical fact in fetal circulation.
Choice C rationale
The placenta is a temporary organ that develops during pregnancy and serves as the primary interface between the mother and fetus. It facilitates the exchange of gases (oxygen and carbon dioxide), nutrients (glucose, amino acids, fatty acids), and waste products (urea, creatinine). It also produces hormones essential for maintaining pregnancy.
Choice D rationale
The placental bed, or intervillous space, is where maternal blood from the spiral arteries bathes the fetal villi. However, maternal and fetal bloodstreams do not mix directly. The placental barrier, a thin membrane, separates the two circulations, allowing for the exchange of substances without the risk of an immune reaction or blood type incompatibility issues. *.
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