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
Answer and explanation
The correct answer is Choice D.
Choice A rationale
A respiratory rate of 16 breaths per minute is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
A Fetal Heart Rate (FHR) of 158 beats per minute is within the normal range (110-160 beats per minute) and would not typically be a cause for concern.
Choice C rationale
While a persistent headache can be a symptom of pre-eclampsia, it is not typically a reason to report to the healthcare provider when a patient is receiving magnesium sulfate to manage pre-eclampsia.
Choice D rationale
A urinary output of 40 mL in 2 hours is less than the normal range (at least 30 mL/hour). This could indicate kidney dysfunction, which is a serious complication of pre-eclampsia. Therefore, this observation should be reported to the healthcare provider.
Correct Answer is B
Explanation
Choice A rationale
Repaglinide is an oral medication used to control blood sugar levels in adults with type 2 diabetes. It is not typically used in pregnant women, especially those unable to control their gestational diabetes with diet and exercise.
Choice B rationale
Insulin is the most common medication used to control blood sugar levels in pregnant women, especially those unable to control their gestational diabetes with diet and exercise.
Choice C rationale
Glipizide is an oral medication used to control blood sugar levels in adults with type 2 diabetes. It is not typically used in pregnant women, especially those unable to control their gestational diabetes with diet and exercise.
Choice D rationale
Acarbose is an oral medication used to control blood sugar levels in adults with type 2
diabetes. It is not typically used in pregnant women, especially those unable to control their gestational diabetes with diet and exercise.
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