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 ["A","B","C","D"]
Explanation
Choice A rationale
Applying warm compresses can help relieve the pain and pressure associated with acute rhinosinusitis by reducing inflammation and promoting sinus drainage.
Choice B rationale
Completing prescribed antibiotics is crucial in treating acute bacterial rhinosinusitis.
Antibiotics help eliminate the bacterial infection causing the inflammation and symptoms.
Choice C rationale
Smoking can irritate the nasal passages and exacerbate the symptoms of rhinosinusitis. Avoiding smoking can help reduce inflammation and promote healing.
Choice D rationale
Swimming, especially in chlorinated pools, can irritate the nasal passages and sinuses, potentially worsening the symptoms of rhinosinusitis. It’s recommended to avoid swimming until the condition has resolved.
Choice E rationale
Periorbital edema is not a normal finding and could indicate a complication of rhinosinusitis, such as a spread of the infection. If a client notices this symptom, they should seek medical attention.
Correct Answer is ["-"]
Explanation
Step 1: The patient’s vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.
Step 2: She was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra is moderate with small clots, no foul odor noted. The fundus is firm at the umbilicus. The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis. There is no pain, redness, or swelling in the calves.
Step 3: A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.
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