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

Explanation

Choice A rationale
Hydration is crucial for children who have recovered from an acute crisis episode of sickle cell anemia. Dehydration can increase the risk of a sickle cell crisis by making the blood more concentrated. Offering fluids to the child multiple times every day can help prevent dehydration.
Choice B rationale
Monitoring the child’s temperature daily can help detect any infections early. Infections can trigger a sickle cell crisis. However, this is not the most critical instruction for the nurse to include in the teaching.
Choice C rationale
Applying cold compresses when the child expresses pain is not recommended. Cold can cause vasoconstriction, which can lead to a decrease in blood flow and potentially trigger a sickle cell crisis.
Choice D rationale
Restricting outdoor play activity to 1 hour per day is not necessarily required for children who have recovered from an acute crisis episode of sickle cell anemia. Physical activity is generally beneficial for children’s health and well-being.

A. Infective endocarditis B. Kawasaki disease C. Hypoplastic left heart syndrome D. Cardiomyopathy E. Transposition of the great vessels

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.

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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

A nurse is discharging a child who has recovered from an acute crisis episode of sickle cell anemia. What instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

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

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

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?