A nurse is attending to a client in labor who is showing late decelerations on the electronic fetal monitor.

What should be the nurse’s initial course of action?

Insert an IV catheter.

Assist the client into the left-lateral position.

Apply a fetal scalp electrode.

Perform a vaginal exam.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While inserting an IV catheter can be a part of the overall management plan for a client showing late decelerations on the electronic fetal monitor, it is not the initial course of action. The primary concern with late decelerations is that they may indicate fetal hypoxia, and the first response should be aimed at improving fetal oxygenation.
Choice B rationale
Assisting the client into the left-lateral position is the correct initial response when late decelerations are observed on the electronic fetal monitor. This position helps to maximize blood flow to the uterus and placenta, thereby improving oxygen delivery to the fetus.
Choice C rationale
Applying a fetal scalp electrode may be useful for obtaining a more accurate fetal heart rate tracing, but it is not the initial response to late decelerations. The priority is to address the potential fetal hypoxia that late decelerations may indicate.
Choice D rationale
Performing a vaginal exam would not be the initial response to late decelerations. While a vaginal exam can provide valuable information about the progress of labor, it does not address the issue of potential fetal hypoxia indicated by late decelerations.

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Correct Answer is ["A","B","D"]

Explanation

Choice A rationale
Infective endocarditis is an infection of the inner lining of the heart’s chambers or valves. It’s typically caused by bacteria entering the blood and settling in the heart. It is considered an acquired heart disease because it develops during a person’s lifetime.
Choice B rationale
Kawasaki disease is an illness that causes inflammation in arteries, veins, and capillaries. It’s most common in children younger than 5 years old. While it’s not a heart disease, it can lead to serious heart problems if not treated.
Choice C rationale
Hypoplastic left heart syndrome is a type of congenital heart defect, meaning it’s present at birth. Therefore, it’s not considered an acquired heart disease.
Choice D rationale
Cardiomyopathy is a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body. It can be acquired or inherited.
Choice E rationale
Transposition of the great vessels is a serious but rare heart defect present at birth (congenital), in which the two main arteries leaving the heart are reversed (transposed). Therefore, it’s not considered an acquired heart disease.

A. Intravenous fluids (IVF) at maintenance rate B. Meperidine IV for pain C. Ice packs to the affected area for 15 min on/15 min off D. Oxygen 2 L/min via nasal cannula

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Choice A rationale
Intravenous fluids (IVF) at maintenance rate is anticipated for the client. Dehydration can increase the viscosity of the blood and promote sickling in clients with sickle cell disease. Therefore, maintaining hydration is crucial in managing sickle cell crises.
Choice B rationale
Meperidine IV for pain is contraindicated for the client. Meperidine has been associated with a higher risk of seizures, especially in clients with kidney dysfunction, which can occur in sickle cell disease due to sickling in the renal vasculature.
Choice C rationale
Ice packs to the affected area for 15 min on/15 min off is nonessential for the client. While cold therapy can help reduce inflammation and numb pain, it can also lead to vasoconstriction, which can potentially exacerbate sickling. Therefore, it’s generally recommended to use warm compresses rather than ice packs in clients with sickle cell disease.
Choice D rationale
Oxygen 2 L/min via nasal cannula is anticipated for the client. Hypoxia can trigger sickling in clients with sickle cell disease, so oxygen therapy is often used to increase oxygen saturation and reduce the risk of sickling.

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A nurse is attending to a client in labor who is showing late decelerations on the electronic fetal monitor. What should be the nurse’s initial course of action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following heart diseases are considered acquired? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

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A nurse is attending to a client in labor who is showing late decelerations on the electronic fetal monitor.

What should be the nurse’s initial course of action?