A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse perform?
Prepare equipment needed for newborn resuscitation
Perform endotracheal suctioning as soon as the fetal head is delivered
Prepare the client for an ultrasound examination
Prepare the client for an emergency cesarean birth
The Correct Answer is A
A. Prepare equipment needed for newborn resuscitation.
A. Preparing equipment needed for newborn resuscitation is the correct action.
Meconium-stained amniotic fluid can increase the risk of meconium aspiration syndrome in the newborn. While the fetal heart rate is reassuring, being prepared for potential newborn resuscitation is prudent given the meconium staining.
B. Performing endotracheal suctioning as soon as the fetal head is delivered is not the current standard of care. The American Academy of Pediatrics (AAP) no longer recommends routine suctioning of meconium-stained infants unless they show signs of respiratory distress, poor muscle tone, or a depressed heart rate.
C. Preparing the client for an ultrasound examination is not the immediate priority. Meconium-stained amniotic fluid may be associated with fetal distress, but the focus should be on the current labor and delivery situation.
D. Preparing the client for an emergency cesarean birth is not the first action.
The presence of meconium staining alone does not necessarily indicate the need for an emergency cesarean birth, especially if the fetal heart rate is reassuring.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Helping the client to the bathroom to void is not the priority in this situation. The urge to push could indicate that the baby is descending, and the nurse should be prepared for imminent delivery.
B. Observing the perineum for signs of crowning is a valid action, but having the client pant during contractions is more appropriate at this stage. It can help prevent rapid descent and potential trauma if delivery is imminent.
C. Having the client pant during the next contractions is the correct action.
Panting during contractions may slow down the urge to push and prevent rapid delivery, especially if the healthcare provider is not present or the delivery is not imminent.
D. Assisting the client into a comfortable position is important, but the priority is to manage the urge to push. Panting can be an effective technique for delaying pushing until the healthcare provider is ready for the delivery.
Correct Answer is A
Explanation
Choice A Reason:
"You should take the medication within 72 hours following unprotected sexual intercourse." This statement is accurate. Levonorgestrel is an emergency contraceptive that is effective when taken within 72 hours (3 days) after unprotected sexual intercourse. It is crucial to use it as soon as possible for optimal effectiveness in preventing pregnancy.
Choice B Reason:
"You should avoid taking this medication if you are on an oral contraceptive." This statement is not accurate. Levonorgestrel can be used as emergency contraception, even if the individual is already on an oral contraceptive. However, it's essential to follow the healthcare provider's guidance.
Choice C Reason:
"If you don't start your period within 5 days of taking this medication, you will need a pregnancy test." This statement is not entirely accurate. While a delayed period may occur after taking levonorgestrel, it does not necessarily indicate pregnancy. If there are concerns about pregnancy, a pregnancy test should be taken a few weeks after using emergency contraception.
Choice D Reason:
"One dose of this medication will prevent you from becoming pregnant for 14 days after taking it." This statement is not accurate. Levonorgestrel is primarily effective in the prevention of pregnancy when taken shortly after unprotected intercourse. It does not provide ongoing protection, and additional contraceptive methods should be considered for future encounters.
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