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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Step 1: The order is to administer Morphine 5mg IV once immediately. The available concentration is 2.5 mg/mL. To find out how many mL of morphine the nurse should prepare for administration, we need to divide the ordered dose by the available concentration.

Step 2: Calculation: 5 mg ÷ 2.5 mg/mL = 2 mL So, the nurse should prepare 2 mL of morphine for administration.

Correct Answer is ["0.3"]

Explanation

Step 1 is to identify the concentration of the medication. From the search results, enoxaparin comes in pre-filled syringes with different concentrations, one of which is 30 mg/0.3 mL56.

Step 2 is to calculate the volume to be administered. Since the client is due to receive 30 mg of enoxaparin and the concentration is 30 mg/0.3 mL, the calculation is (30 mg ÷ 30 mg) × 0.3 mL. The final calculated answer is 0.3 mL.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has received an order to administer Morphine 5mg IV once immediately. The available concentration is 2.5 mg/mL. How many mL of morphine should the nurse prepare for administration?

Correct Answer is C

Explanation

A client is due to receive a subcutaneous injection of enoxaparin, 30 mg. How many mL should the nurse administer if the answer is to be rounded to the nearest tenth? (Use a leading zero if applicable.

Correct Answer is ["0.3"]

Explanation

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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?