A nurse is caring for a client who is experiencing a decrease in the fetal heart rate. Which of the following actions should the nurse take?
Administer oxygen at 10 L/min via a non-rebreather mask.
Apply a fetal scalp electrode.
Change the client’s position.
Increase the rate of the IV infusion.
The Correct Answer is C
Choice A rationale
Administering oxygen at 10 L/min via a non-rebreather mask is a common intervention for fetal distress, but it is not the first action a nurse should take when a decrease in fetal heart rate is observed.
Choice B rationale
Applying a fetal scalp electrode can provide a more accurate fetal heart rate reading, but it is an invasive procedure and is not the first action a nurse should take when a decrease in fetal heart rate is observed.
Choice C rationale
Changing the client’s position is the correct action. This is often the first intervention for a decrease in fetal heart rate because it can relieve possible compression of the umbilical cord, which can improve fetal circulation and increase the fetal heart rate.
Choice D rationale
Increasing the rate of the IV infusion can increase maternal blood volume and improve placental blood flow, but it is not the first action a nurse should take when a decrease in fetal heart rate is observed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The Babinski reflex is a normal reflex in infants that disappears by 12 months of age. It involves fanning out of the toes when the sole of the foot is stroked, and it doesn’t promote latching during breastfeeding.
Choice B rationale
The stepping reflex is a primitive reflex that makes newborns appear to take steps or dance when held upright with their feet touching a solid surface. It doesn’t promote latching during breastfeeding.
Choice C rationale
The rooting reflex helps promote latching during breastfeeding. When the corner of the baby’s mouth is touched, the baby will turn his or her head and open his or her mouth to follow and “root” in the direction of the stroking. This helps the baby find the breast or bottle to start feeding.
Choice D rationale
The Moro reflex, also known as the startle reflex, involves the baby throwing back his or her head, extending out the arms and legs, crying, then pulling the arms and legs back in. It doesn’t promote latching during breastfeeding.
Correct Answer is A
Explanation
Choice A rationale
If the fundus is palpable to the right of the midline, it may indicate that the bladder is distended. A full bladder can displace the uterus to one side.
Choice B rationale
Frequent uterine contractions are not typically associated with bladder distention. These contractions are a normal part of the postpartum period as the uterus returns to its pre- pregnancy size.
Choice C rationale
Having less than 2.5 cm of rubra lochia on a perineal pad does not indicate bladder distention. This is a normal finding in the postpartum period.
Choice D rationale
An increased thirst is not typically associated with bladder distention. It is a common symptom in the postpartum period due to fluid shifts and breastfeeding.
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