A nurse is caring for a client who is in active labor and notes persistent late decelerations on the fetal monitor.Which of the following are the priority nursing actions? (Select all that apply.)
Document the findings in the client's medical record.
Notify the healthcare provider immediately.
Administer a tocolytic medication to stop contractions.
Reposition the client to a side-lying position.
Administer pain medication to the client.
Administer oxygen to the client.
Correct Answer : B,D,F
Choice A rationale
Documenting the findings in the client's medical record is important but is not the priority action when persistent late decelerations are noted. Immediate interventions are needed to improve fetal oxygenation.
Choice B rationale
Notifying the healthcare provider immediately is crucial as persistent late decelerations indicate fetal distress. The provider can decide on further interventions to ensure the safety of the mother and fetus.
Choice C rationale
Administering a tocolytic medication to stop contractions is not appropriate in this scenario. The priority is to improve fetal oxygenation, not to stop contractions.
Choice D rationale
Repositioning the client to a side-lying position can help improve blood flow to the uterus and placenta, enhancing fetal oxygenation. This is a priority intervention.
Choice E rationale
Administering pain medication to the client is not a priority in this situation. The focus should be on addressing fetal distress and improving oxygenation.
Choice F rationale
Administering oxygen to the client increases the oxygen available to the fetus and is a priority intervention when persistent late decelerations are noted.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The first stage of labor, transition phase, is characterized by rapid cervical dilation from 7 cm to 10 cm, intense contractions, and strong desire to push. This client's cervix is only 3 cm dilated, indicating that she is not in the transition phase.
Choice B rationale
The second stage of labor, active phase, is the period from full cervical dilation to the birth of the baby. This stage involves active pushing and the descent of the baby through the birth canal. This client's cervix is not fully dilated, so she cannot be in the second stage.
Choice C rationale
The second stage of labor, latent phase, does not exist. The latent phase is part of the first stage of labor, not the second stage. This choice is incorrect because it misrepresents the stages of labor.
Choice D rationale
The first stage of labor, latent phase, is characterized by regular contractions, cervical effacement, and dilation up to 4 cm. This client's cervix is 80% effaced and 3 cm dilated, indicating that she is in the latent phase of the first stage of labor.
Correct Answer is ["7"]
Explanation
Step 1 is 2800 grams × 2.5 mg/kg. 2800 grams × 2.5 mg/kg = 7000 mg/kg.
Step 2 is 7000 mg ÷ (1000 mg/kg). 7000 mg ÷ (1000 mg/kg) = 7 mg.
Final calculated answer: 7 mg.
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