A nurse is caring for a client who is in active labor and notes late decelerations in the FHR on the external fetal monitor. Which of the following actions should the nurse take first?

Change the client's position.

Palpate the uterus to assess for tachysystole.

Increase the client's IV infusion rate.

Administer oxygen at 10 L/min via a nonrebreather mask.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

When late decelerations are noted in the fetal heart rate (FHR) tracing, it indicates that the fetal oxygen supply may be compromised. The nurse should first change the client's position, such as moving her to the left lateral position or a hands-and-knees position, to improve uteroplacental blood flow and relieve pressure on the vena cava.

Choice B rationale:

Palpating the uterus to assess for tachysystole is not the priority action when late decelerations are observed. Tachysystole refers to excessively frequent uterine contractions and may contribute to fetal distress, but the immediate concern is addressing the decelerations.

Choice C rationale:

Increasing the client's IV infusion rate may not address the underlying cause of late decelerations. While maintaining hydration is important, it's not the first action to take in this situation.

Choice D rationale:

Administering oxygen at 10 L/min via a non-rebreather mask may be beneficial for the client and fetus, but it is not the first action to take. The nurse should address the position change first to improve oxygenation through better blood flow before considering supplemental oxygen.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

An axillary temperature of 36.5°C (97.7°F) is within the normal range for a newborn. Normal axillary temperature for a newborn is typically between 36.5°C to 37.5°C (97.7°F to 99.5°F).

Choice B rationale:

This is the correct choice. Nasal flaring in a newborn is a concerning sign and may indicate respiratory distress. It suggests that the baby is having difficulty breathing and should be reported to the provider for further evaluation.

Choice C rationale:

A heart rate of 158/min is within the normal range for a newborn. The normal heart rate for a newborn can range from 100 to 160 beats per minute.

Choice D rationale:

Having one void since birth is not a concerning finding for a 10-hour-old newborn. In the early hours of life, the frequency of voids may vary, but the baby should have an increasing number of wet diapers in the following days.

A. "I will notify my provider if I experience chest pain, shortness of breath, or leg pain.” B. "I will use an alternative form of birth control if I miss three pills.” C. "If I miss three pills, I will double up each day until back on schedule.” D. "I will have to have follow-up appointments with my provider while taking this medication.”

Correct Answer is C

Explanation

Choice A rationale:

This statement indicates that the client understands the potential side effects of oral contraception and the importance of reporting them promptly to their healthcare provider. Chest pain, shortness of breath, or leg pain can be indicative of serious complications, such as blood clots, which can occur with oral contraceptive use.

Choice B rationale:

This statement demonstrates the client's understanding of what to do if they miss three pills. Using an alternative form of birth control is a responsible action to prevent unintended pregnancies, as missing multiple pills can decrease contraceptive effectiveness.

Choice C rationale:

This statement reveals a misunderstanding of the appropriate action to take if the client misses three pills. Instead of doubling up, the client should be instructed to take the missed pill as soon as they remember and continue taking the pills as usual. Doubling up can increase the risk of side effects and won't necessarily prevent pregnancy.

Choice D rationale:

This statement indicates that the client comprehends the need for follow-up appointments while on oral contraception. Regular follow-ups are essential to monitor the client's health, address any concerns, and ensure the effectiveness of the chosen contraceptive method.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR on the external fetal monitor. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who is 10 hr old. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse has provided education to a client who has been prescribed oral contraception. Which of the following client statements indicates a need for further education?

Correct Answer is C

Explanation

A client has been prescribed raloxifene. As the nurse, you know that raloxifene is used to treat:.

A nurse is planning care for a client who is 2 weeks postpartum and has mastitis. Which of the following interventions should the nurse include? (Select all that apply.)

A home care nurse is following up with a postpartum client. Which of the following is a risk factor that places this client at risk for postpartum depression?

A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down” and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take?

A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?

A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?