A nurse is assisting in the care of a client in the intrapartum unit.
Which of the following actions should the nurse take? Select all that apply.
Increase the rate of maintenance IV fluid.
Assist the client to a lateral position.
Apply oxygen via nasal cannula at 2L.
Administer misoprostol.
Notify the primary health care provider of fetal heart rate changes.
Correct Answer : A,B,E
Choice A rationale: Increasing the rate of maintenance IV fluids improves maternal intravascular volume and enhances uteroplacental perfusion. Late decelerations are indicative of uteroplacental insufficiency, where fetal oxygenation is compromised during contractions. By increasing fluid volume, the nurse can help optimize cardiac output and improve oxygen delivery to the fetus, potentially reducing the frequency or severity of late decelerations.
Choice B rationale: Assisting the client into a lateral position, preferably left lateral, helps relieve pressure on the inferior vena cava and improves venous return. This position enhances uteroplacental blood flow and oxygen delivery to the fetus. It is a first-line intervention for late decelerations, as it can reduce fetal hypoxia by improving maternal-fetal circulation without requiring pharmacologic measures.
Choice C rationale: Oxygen via nasal cannula at 2 L is insufficient to address fetal distress. When supplemental oxygen is indicated for intrauterine resuscitation, it should be administered via a non-rebreather mask at 10 L/min to maximize maternal oxygenation and fetal oxygen delivery. A nasal cannula at 2 L does not provide the high concentration needed to improve fetal oxygenation during late decelerations.
Choice D rationale: Misoprostol is a prostaglandin used for cervical ripening and labor induction. It is contraindicated in the presence of fetal distress, such as late decelerations, because it can cause uterine hyperstimulation and worsen fetal hypoxia. Administering misoprostol in this context could exacerbate the situation and increase the risk of adverse outcomes for the fetus.
Choice E rationale: Notifying the primary health care provider is essential when late decelerations are observed, as they indicate potential fetal compromise. Timely communication allows for further evaluation and potential interventions, such as adjusting oxytocin, initiating intrauterine resuscitation, or preparing for operative delivery if the fetal status does not improve. This action ensures collaborative and responsive care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
? Rationale for Correct Answers
Diabetic diet is appropriate because the client meets diagnostic criteria for gestational diabetes mellitus (GDM). The 3-hour oral glucose tolerance test (OGTT) shows two or more elevated values:
- 1-hour: 220 mg/dL (normal <180 mg/dL)
- 2-hour: 165 mg/dL (normal <140 mg/dL)
- 3-hour: 142 mg/dL (normal 70–115 mg/dL)
According to the American Diabetes Association and ACOG, GDM is diagnosed when at least two values exceed thresholds. GDM increases risks for macrosomia, preeclampsia, and neonatal hypoglycemia, and requires dietary management as first-line therapy.
30 cal/kg/day is the recommended caloric intake for overweight or obese pregnant individuals with GDM. Caloric needs are based on pre-pregnancy weight:
- Normal BMI: 30–35 kcal/kg/day
- Overweight (BMI 25–29.9): 25 kcal/kg/day
- Obese (BMI ≥30): 30 kcal/kg/day is often used to balance fetal growth and glycemic control.
❌ Rationale for Incorrect Response 1 Options
Low-sodium diet is used for hypertension or preeclampsia, but this client has no signs of preeclampsia (e.g., proteinuria, headache, visual changes, epigastric pain).
High-protein diet is not a standard intervention for GDM and may worsen insulin resistance if not balanced.
Gluten-free diet is indicated for celiac disease, which is not present here.
❌ Rationale for Incorrect Response 2 Options
15–25 cal/kg/day are too low for pregnancy and may risk fetal growth restriction, especially in obese clients.
20 cal/kg/day is used in severe obesity or when caloric restriction is medically necessary, but not standard for GDM.
25 cal/kg/day is more appropriate for overweight (not obese) clients.
? Take-Home Points
- GDM is diagnosed with ≥2 abnormal values on a 3-hour OGTT.
- Dietary therapy is first-line management for GDM, focusing on controlled carbohydrate intake.
- Obese pregnant clients with GDM should receive ~30 kcal/kg/day based on pre-pregnancy weight.
- GDM increases risks for maternal and fetal complications and requires close monitoring.
Correct Answer is ["A","B","C","E","F"]
Explanation
Choice A rationale: Rechecking the newborn’s temperature is essential because the earlier reading of 36.3°C (97.3°F) was below the normal range of 36.5–37.5°C. Hypothermia in neonates can exacerbate hypoglycemia by increasing metabolic demands. Monitoring temperature ensures thermoregulation is maintained, which is critical for stabilizing glucose levels and preventing further complications in the early neonatal period.
Choice B rationale: Scheduling a lactation consult is appropriate due to the newborn’s initial difficulty latching. Effective breastfeeding is crucial for maintaining adequate glucose levels, especially in a macrosomic infant at risk for hypoglycemia. A lactation consultant can assess latch technique, feeding cues, and milk transfer to ensure the newborn receives sufficient nutrition and to support maternal confidence and bonding.
Choice C rationale: Rechecking the glucose level is warranted because the newborn previously had a hypoglycemic reading of 35 mg/dL, followed by a borderline normal value of 50 mg/dL. Continued monitoring is necessary to ensure glucose stability, especially in a macrosomic infant who may have persistent hyperinsulinemia. Serial glucose checks help detect recurrent hypoglycemia and guide further interventions.
Choice D rationale: Reinforcing hourly breastfeeding is not evidence-based and may lead to feeding fatigue for both the newborn and parent. Newborns typically feed every 2 to 3 hours. Overfeeding attempts can cause stress and interfere with effective feeding. Instead, feeding should be based on hunger cues and guided by lactation support to ensure quality rather than quantity of feeds.
Choice E rationale: Ensuring the newborn is tightly swaddled helps maintain body temperature and provides a calming, secure environment. Swaddling reduces energy expenditure, which is important in preventing further glucose depletion. It also helps soothe jitteriness and supports neuromuscular tone, both of which are affected in hypoglycemic states. Proper swaddling is a key nonpharmacologic intervention in neonatal care.
Choice F rationale: Encouraging skin-to-skin contact promotes thermoregulation, stabilizes glucose levels, and enhances breastfeeding success. This practice stimulates oxytocin release, improves maternal-infant bonding, and reduces stress responses in the newborn. For infants at risk of hypoglycemia, skin-to-skin contact is a first-line supportive measure that complements nutritional and metabolic interventions.
Choice G rationale: Maintaining an intravenous catheter for glucose administration is not indicated at this time. The newborn’s glucose level improved to 50 mg/dL after feeding, and the infant is now stable, alert, and feeding. IV glucose is reserved for symptomatic hypoglycemia unresponsive to feeding or when glucose levels remain critically low. In this case, noninvasive measures are sufficient.
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