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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A: Engaging in moderate physical activity during pregnancy, such as jogging, is generally safe and beneficial for pregnant women who have uncomplicated pregnancies. Staying hydrated, avoiding excessive exertion, and preventing overheating are important considerations during exercise.

B: The use of saunas and hot tubs during pregnancy is generally not recommended at any trimester, as they can cause hyperthermia and pose risks to the developing fetus.

C: Limiting exercise to only stretching on a mat is not appropriate during pregnancy. Regular physical activity is generally encouraged, provided there are no specific contraindications or complications.

D: Completely avoiding exercise during pregnancy is not recommended, as moderate and appropriate physical activity can have various benefits for both the mother and the baby.

A. 1 cm below the umbilicus B. 3 cm below the umbilicus C. 2 cm above the umbilicus D. 3 cm above the umbilicus

Correct Answer is C

Explanation

A. 1 cm below the umbilicus: This is too low for a client at 22 weeks of gestation.

B. 3 cm below the umbilicus: This is also too low for a client at 22 weeks of gestation.

C. 2 cm above the umbilicus: At 22 weeks of gestation, the fundus should be palpated about 2 cm above the umbilicus, which is at approximately the level of the maternal belly button.
D. 3 cm above the umbilicus: This is too high for a client at 22 weeks of gestation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate?

Correct Answer is A

Explanation

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

Correct Answer is C

Explanation

A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching?

A nurse is teaching a client who is at 18 weeks of gestation and is to undergo an amniocentesis. The nurse should explain that the purpose of this test is to identify which of the following? (Select all that apply.)

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

A nurse is caring for a client who is in the first stage of labor and is using patternpaced breathing. The client says she feels lightheaded, and her fingers are tingling. Which of the following actions should the nurse take?

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?

A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?