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
"Monitor perineal pads for clots.”. This is incorrect because while monitoring for clots is important, it does not address the underlying issue causing the fundal deviation.
Choice B rationale
"Assist the client to empty her bladder.”. This is correct because a full bladder can cause the uterus to deviate and impede uterine involution. Emptying the bladder helps the uterus to contract properly and return to its normal position.
Choice C rationale
"Notify the provider.”. This is incorrect because the immediate action should be to address the potential cause of the deviation (a full bladder), which can be managed by the nurse.
Choice D rationale
"Administer a prescribed analgesic.”. This is incorrect because administering pain relief does not address the cause of the fundal deviation and does not alleviate the potential issue.
Correct Answer is []
Explanation
An ectopic pregnancy is most likely due to the combination of symptoms: dizziness, pale skin, cool extremities, low blood pressure (86/48 mm Hg), and high heart rate (120/min). The soft and non-tender abdomen with no palpable contractions also suggests an ectopic pregnancy rather than other conditions. The low hematocrit (25%) and hemoglobin (9 g/dL) indicate significant blood loss, a hallmark of ectopic pregnancy.
Administer methotrexate is important to stop the growth of the embryo in an ectopic pregnancy. Insert a large-bore peripheral IV catheter to manage blood loss and prepare for potential surgery.
Monitoring beta human chorionic gonadotropin (hCG) levels is crucial to confirm the diagnosis and monitor treatment response. Platelet count should be monitored due to the risk of bleeding associated with an ectopic pregnancy.
Placenta previa usually presents with painless vaginal bleeding, which is absent in this case. Chorioamnionitis is typically associated with infection signs like fever, uterine tenderness, and elevated white blood cell count, not primarily dizziness and low blood pressure. Cervical insufficiency usually presents with painless cervical dilation, leading to preterm birth, not the acute signs seen here. Vaginal bleeding is a symptom, not a diagnosis, and this client reports no vaginal bleeding.
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