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
The correct answer is C. Continuous contraction lasting 2 min.
A. Pressure on the perineum causing the client to bear down is a common sign in the later stages of labor when the cervix is fully dilated. It is not typically a cause for immediate concern during the admission phase.
B. Expulsion of clear fluid from the vagina may be amniotic fluid, which can indicate rupture of membranes. While important to note, it is not as urgent as a prolonged contraction.
C. Continuous contraction lasting 2 min is a concerning finding and should be reported first.
A contraction lasting 2 minutes is excessively long and may lead to decreased uterine blood flow, affecting fetal oxygenation. It requires prompt attention from the healthcare provider.
D. Expulsion of a blood-tinged mucous plug, also known as the "bloody show," is a common occurrence in early labor and is not as urgent as the prolonged contraction.
Correct Answer is D
Explanation
A. Contractions lasting longer than 90 seconds: Prolonged contractions lasting longer than 90 seconds may indicate uterine hyperstimulation, which can compromise fetal oxygenation and lead to fetal distress. This finding should be reported to the provider promptly for further evaluation and management.
B. Client reports feeling contractions in the lower back: This is a common sensation during labor and may not necessarily indicate a complication. However, if associated with other signs of fetal distress, it should be reported.
C. Contractions occurring every 3 to 5 minutes: This frequency is within the normal range for the active phase of labor and does not necessarily indicate a problem. However, it is essential to consider the duration and intensity of contractions along with this frequency.
D. Contractions are strong in intensity: While strong contractions are typical during the active phase of labor, the intensity alone may not be a cause for concern unless they are associated with uterine hyperstimulation.
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