A nurse is assisting with the care of a client who is in active labor.The fetal monitor tracing shows late decelerations.
Which of the following actions should the nurse take first?

Elevate the client's legs.

Turn the client onto their side.

Palpate the client's uterus.

Increase the client's IV fluid infusion rate.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Elevating the client's legs is incorrect as an initial intervention. It is more important to address the potential cause of the late decelerations first.

Choice B rationale

Turning the client onto their side is correct. This intervention can improve blood flow to the fetus and reduce the pressure on the vena cava, potentially alleviating late decelerations.

Choice C rationale

Palpating the client's uterus is not the first action. It is essential to address maternal positioning and oxygenation issues first.

Choice D rationale

Increasing the client's IV fluid infusion rate may help, but it is not the initial action. Positioning changes can have an immediate effect on fetal oxygenation.

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Correct Answer is B

Explanation

Choice A rationale

Using a disposable razor for shaving while taking warfarin can increase the risk of cuts and bleeding, which should be avoided due to the anticoagulant effects of warfarin.

Choice B rationale

Oral contraceptives should not be taken while on warfarin because they can increase the risk of blood clots, counteracting the effect of the anticoagulant.

Choice C rationale

Stopping warfarin in 2 weeks is incorrect advice, as the duration of therapy varies depending on the condition being treated and the individual's response to the medication.

Choice D rationale

Taking 650 milligrams of aspirin for leg discomfort is not advised while on warfarin, as aspirin can increase the risk of bleeding by affecting platelet function and the blood clotting process.

A. Nausea. B. Facial flushing. C. Urine output 40 mL/hr. D. Respiratory rate 10/min.

Correct Answer is D

Explanation

Choice A rationale

Nausea can be a side effect of magnesium sulfate, but it is not a specific indication of toxicity. Other symptoms are more directly indicative of magnesium sulfate overdose.

Choice B rationale

Facial flushing is a common side effect of magnesium sulfate but is not a sign of toxicity. It typically occurs at therapeutic levels and is not a reliable indicator of overdose.

Choice C rationale

Urine output of 40 mL/hr is within normal limits for an adult and does not indicate magnesium sulfate toxicity. However, significantly decreased urine output could be concerning.

Choice D rationale

Respiratory rate of 10/min is a critical sign of magnesium sulfate toxicity. Magnesium sulfate can cause respiratory depression, and a rate of 10 breaths per minute or less indicates that the patient may be experiencing toxic effects, necessitating immediate medical intervention.

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A nurse is assisting with the care of a client who is in active labor.The fetal monitor tracing shows late decelerations.Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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A nurse is assisting with the care of a client who is in active labor.The fetal monitor tracing shows late decelerations.
Which of the following actions should the nurse take first?