A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?
Administer oxygen using a nonrebreather mask.
Elevate the client's legs.
Place the client in the lateral position.
Increase the rate of maintenance IV infusion.
The Correct Answer is C
A) Administer oxygen using a nonrebreather mask: While oxygen may be necessary if there are signs of fetal distress, the priority action in this situation is to reposition the client and relieve potential cord compression.
B) Elevate the client's legs: Elevating the client's legs is not the most appropriate action in this situation and may not address the cause of the decelerations.
C) Place the client in the lateral position: This is the correct answer. The described pattern of the fetal heart rate (slowdown after the start of a contraction with the lowest rate occurring after the peak of the contraction) suggests late decelerations, which are often caused by uteroplacental
insufficiency or cord compression. Placing the client in the lateral position can help alleviate potential compression of the umbilical cord and improve fetal oxygenation.
D) Increase the rate of maintenance IV infusion: Increasing the IV infusion rate may not be the most appropriate action for late decelerations. Repositioning the client is the priority in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Bowel prep protocols are not required for an amniocentesis procedure, as it involves sampling amniotic fluid from the uterus, not the bowel.
Choice B: Emptying the bladder before the procedure is important to improve comfort and minimize the risk of accidental puncture during the amniocentesis.
Choice C: It is essential to have a full bladder for some ultrasound procedures, but it is not necessary for an amniocentesis. A full bladder can help push the uterus upward and make it easier to visualize the fetus during the ultrasound, but it is not relevant to the amniocentesis procedure.
Choice D: Washing the abdomen with soap and water is not a required step for an amniocentesis procedure. The procedure involves sterile preparation of the abdomen using an antiseptic
solution.
Correct Answer is B
Explanation
Choice A reason:
Monitoring weight gain is correct because appropriate weight gain helps support fetal growth and reduces risks of complications such as gestational diabetes and preeclampsia.
Choice B reason:
Using nonprescription medications without provider approval is unsafe since many over-the-counter drugs (like NSAIDs or decongestants) can harm the fetus. This shows a need for further teaching.
Choice C reason:
Telling the provider before using home remedies is appropriate, as some herbs or supplements may be unsafe in pregnancy.
Choice D reason:
Reducing stress is correct because high maternal stress can negatively affect pregnancy outcomes and fetal development.
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