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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Emotional lability.
A. Emotional lability: Emotional lability refers to rapid and unpredictable changes in mood, with intense emotions shifting quickly from one extreme to another. It is a common aspect of the emotional adaptation to pregnancy and is often influenced by hormonal changes.
B. Focusing phase: The focusing phase is a concept related to the process of adapting to pregnancy. It involves the pregnant individual focusing on the reality of the pregnancy and incorporating the changes into their self-concept. While mood changes may occur during this phase, the client's statement more specifically reflects emotional lability.
C. Cognitive restructuring: Cognitive restructuring involves changing thought patterns to modify emotional responses. The client's statement does not necessarily indicate a deliberate process of changing thought patterns but rather describes the emotional swings often associated with pregnancy.
D. Couvade syndrome: Couvade syndrome refers to a phenomenon where a partner experiences symptoms that mimic pregnancy symptoms. It is not applicable in this context as the client is describing her own emotional experiences related to pregnancy.
Correct Answer is C
Explanation
Choice A Reason:
"I will get injections of the medication once daily until my labor stops." Terbutaline is typically administered as a subcutaneous injection or orally, but the frequency can vary. It is often given as needed or on a scheduled basis, depending on the healthcare provider's instructions. However, "once daily until labor stops" is not a typical approach.
Choice B Reason:
"My blood sugar may be low while I'm on this medication." While terbutaline can affect glucose metabolism, it is more commonly associated with hyperglycemia (high blood sugar) rather than hypoglycemia (low blood sugar).
Choice C Reason:
"I will have blood tests because my potassium might decrease." Terbutaline, a beta-2 adrenergic agonist, can potentially lead to hypokalemia (a decrease in potassium levels). Monitoring potassium levels through blood tests is important during terbutaline therapy.
Choice D Reason:
"My blood pressure may increase while I'm on this medication." Terbutaline is known to cause cardiovascular side effects, but an increase in blood pressure is not a common effect. It is more associated with tachycardia (increased heart rate) and potential hypotension. Monitoring blood pressure is still important, but an increase is less likely compared to other cardiovascular effects.
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