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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A client whose labor lasted for 6 hours is not necessarily a priority unless other complications are present. Duration of labor alone does not indicate an urgent need for immediate attention postpartum.
Choice B rationale
A client who received magnesium sulfate during labor should be seen first due to the potential for serious side effects such as respiratory depression, hypotonia in the newborn, and maternal complications. Magnesium sulfate is used to prevent seizures in clients with preeclampsia and requires close monitoring.
Choice C rationale
A client with a history of oligohydramnios needs monitoring, but this condition alone does not take precedence over the immediate postpartum risks associated with magnesium sulfate.
Choice D rationale
A client whose newborn is having difficulty latching-on needs support and assistance with breastfeeding. While important, this issue is not as urgent as monitoring the effects of magnesium sulfate in the client described in Choice B.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.