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

Choice A: The first priority assessment finding to report to the provider is contractions lasting 2 minutes and with no rest between contractions. Prolonged contractions without adequate rest can lead to uterine hyperstimulation and fetal distress, potentially compromising the wellbeing of both the client and the baby. The provider needs to be informed immediately for further

evaluation and intervention.

Choice B: Pressure on the perineum and the desire to bear down indicate that the client is experiencing the urge to push, which is expected during the second stage of labor, not during the active phase of the first stage. It is not the first priority to report.

Choice C: Clear fluid discharge from the vagina can indicate rupture of membranes, but it is not an immediate concern unless the fluid is meconiumstained or there are other signs of fetal distress.

Choice D: Passage of a bloodtinged mucous plug (also known as "bloody show") is a common sign that labor is approaching, but it is not an immediate concern unless there are other signs of labor progression or complications. It is not the first priority to report.

A. This test assesses fetal lung maturity in the premature fetus. B. It provides an assessment of various signs of physical and physiological wellbeing in the fetus. C. This test identifies an Rh incompatibility between an Rhnegative mother and her unborn fetus. D. It is a maternal blood screening test to identify neural tube defects (also known as spinal defects) and Down syndrome in the fetus.

Correct Answer is D

Explanation

Choice A: Fetal lung maturity is not assessed through maternal serum alphafetoprotein testing. It is usually evaluated through tests such as amniocentesis or specialized ultrasound examinations closer to the third trimester.
Choice B: The maternal serum alphafetoprotein test specifically screens for certain birth defects and genetic conditions in the fetus, rather than general signs of physical and physiological
wellbeing.

Choice C: The maternal serum alphafetoprotein test is not used to identify Rh incompatibility. Rh incompatibility is determined through blood tests that assess the Rh factor of the mother's blood and the Rh status of the baby.
Choice D: The maternal serum alphafetoprotein test is a blood screening test that can identify neural tube defects (such as spina bifida) and chromosomal abnormalities (such as Down syndrome) in the fetus. The test measures the levels of alphafetoprotein in the mother's blood, and abnormal levels may indicate the need for further diagnostic testing.

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Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is at 38 weeks of gestation and is in the active phase of the first stage of labor. Which of the following assessment findings is the first priority for the nurse to report to the provider?

Correct Answer is A

Explanation

A nurse is caring for a client who is scheduled for a maternal serum alphafetoprotein test at 15 weeks of gestation. The nurse provides which of the following explanations about this test to the client?

Correct Answer is D

Explanation

A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide?

A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when he observes which of the following patterns?

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?

A nurse in a family planning clinic is caring for a 17 year old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make?

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?