A laboring client has a variable deceleration on the fetal monitor.
What is the first action that the nurse should take?
Administer oxygen via facemask.
Turn off the oxytocin infusion.
Change the client’s position.
Assess cervical dilatation.
Assess cervical dilatation.
The Correct Answer is C
Choice A rationale
Administering oxygen via a facemask is an intervention that can be used if the baby shows signs of distress or if the decelerations do not improve with other interventions. However, it is not the first action that should be taken.
Choice B rationale
Turning off the oxytocin infusion could be an appropriate action if the mother is receiving oxytocin and the baby is showing signs of distress. However, it is not the first action that should be taken.
Choice C rationale
Changing the client’s position is the correct first action for variable decelerations. This can relieve potential cord compression and improve fetal oxygenation.
Choice D rationale
Assessing cervical dilation is an important part of monitoring labor progress, but it is not the first action that should be taken in response to variable decelerations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While protein is an essential nutrient for overall health and wellbeing, increasing protein intake alone is unlikely to significantly improve hemoglobin levels. Hemoglobin is a protein in red blood cells that carries oxygen, and its production depends on having enough iron, vitamin B12, and folic acid, not just protein.
Choice B rationale
During pregnancy, the volume of blood in a woman’s body increases to support the growing fetus. This increase in blood volume can dilute the blood, which can lead to a decrease in the concentration of red blood cells and hemoglobin, a condition known as physiological anemia of pregnancy. This is a normal part of pregnancy and is typically not a cause for concern.
Choice C rationale
While it’s true that many women experience changes in their hemoglobin levels during pregnancy, it’s not accurate to say that almost all women at 28-weeks gestation have anemia. Anemia is defined as a level of hemoglobin that’s lower than normal, and the normal range can vary. However, it’s important to note that the normal range for hemoglobin does decrease during pregnancy.
Choice D rationale
Iron is a key component of hemoglobin, and iron deficiency is a common cause of anemia. If a pregnant woman’s hemoglobin levels are low, taking an iron supplement might help increase these levels. However, it’s important to talk to a healthcare provider before starting any new medication or supplement.
Correct Answer is B
Explanation
Choice A rationale
Immediately after delivery, the breasts of a new mother are not likely to remain the same as before delivery. Hormonal changes during pregnancy prepare the breasts for lactation, and these changes do not typically revert immediately after delivery.
Choice B rationale
On the first postpartum day, the breasts of a new mother are most likely to be filling and secreting colostrum. Colostrum is the first form of milk produced by the mammary glands, and it usually starts to be produced during pregnancy and continues during the early days of breastfeeding.
Choice C rationale
An immediate let-down response is not typically observed on the first postpartum day. The letdown reflex, which releases milk from the breast, usually becomes more pronounced after the first few days of breastfeeding.
Choice D rationale
While the breasts may become larger due to milk production, they are not typically very tender to touch on the first postpartum day. Tenderness may occur later, especially if complications like engorgement or mastitis develop.
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