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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The newborn's legs flexing at the knees and hips when pressure is applied to the soles indicates the stepping reflex, an expected response.
Choice B rationale
Newborns do not typically keep their eyes closed when tapped on the forehead; this is not an expected reflex response.
Choice C rationale
The palmar grasp reflex, where the newborn's fingers curl around the nurse's finger, is an expected and normal finding in newborns, indicating healthy neurological function.
Choice D rationale
The rooting reflex, where the newborn turns their head when their cheek is touched, is expected and demonstrates feeding readiness and normal neural development. .
Correct Answer is B
Explanation
Choice A rationale
1/2 cup (4 oz) orange juice provides about 55 micrograms of folate. While it is a good source of vitamin C and other nutrients, it does not contain as much folate compared to leafy greens.
Choice B rationale
1 cup cooked spinach contains approximately 263 micrograms of folate, making it one of the richest sources of this essential vitamin. Folate is crucial for DNA synthesis and cell division, especially during pregnancy.
Choice C rationale
1 large egg contains about 24 micrograms of folate. Although eggs offer several nutrients like protein and vitamins, their folate content is relatively low compared to green vegetables.
Choice D rationale
1 cup pasta has around 102 micrograms of folate, assuming it is enriched pasta. While it contributes to daily folate intake, it does not compare to the high levels found in spinach.
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