A nurse is attending to a client in active labor and observes late decelerations on the fetal monitor.
What should be the nurse’s priority action?
Administer oxygen via face mask.
Increase the rate of the IV fluid infusion.
Elevate the client’s legs.
Position the client on her side.
The Correct Answer is D
Choice A rationale
Administering oxygen via face mask is a common intervention for various complications during labor. However, it is not the priority action when late decelerations are observed on the fetal monitor. Late decelerations are a sign of fetal hypoxia, which is often caused by uteroplacental insufficiency. While oxygen administration can help increase the overall oxygen available, it does not directly address the cause of the late decelerations.
Choice B rationale
Increasing the rate of the IV fluid infusion can help improve maternal circulation and potentially increase placental perfusion. However, this intervention is not the most immediate or effective response to late decelerations.
Choice C rationale
Elevating the client’s legs is not the recommended action in response to late decelerations. This position does not alleviate the cause of late decelerations and can actually impede blood flow to the uterus.
Choice D rationale
Positioning the client on her side, specifically the left side, is the priority action when late decelerations are observed. This position helps to maximize blood flow to the uterus and placenta, thereby improving oxygen delivery to the fetus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. In a cephalic (head-down) presentation, fetal heart tones are typically heard below the umbilicus.
B. A posterior position refers to the fetal back facing the mother's back, but it does not affect the heart tone location significantly.
C. A transverse lie would place the fetal heart tones at the lateral sides of the abdomen, not above the umbilicus.
D. In a frank breech position (buttocks presenting first), fetal heart tones are usually heard above the umbilicus, as the fetal head is positioned in the upper uterus.
Correct Answer is B
Explanation
Cervical dilation is a key sign that a patient is in labor. As labor progresses, the cervix dilates to allow the baby to pass through the birth canal. Other signs of labor can include regular contractions, rupture of membranes (amniotic fluid present in the vaginal vault), and changes in vaginal discharge.
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