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
Observing the perineum for signs of crowning is important, but it doesn’t address the immediate need to manage the client’s urge to push. By the time crowning is visible, delivery is imminent, and the urge to push should have been managed earlier.
Choice B rationale
Helping the client to the bathroom to void might relieve some pressure but is not the immediate priority when the client feels the urge to push. Voiding can wait until contractions are managed.
Choice C rationale
Assisting the client into a supine position is not ideal for managing the urge to push. A supine position can increase discomfort and does not facilitate optimal delivery dynamics.
Choice D rationale
Assisting the client with quick shallow breathing helps manage the urge to push and prevents premature pushing, reducing the risk of cervical injury and aiding controlled delivery.
Correct Answer is D
Explanation
Choice A rationale
Ergonovine maleate is used to treat postpartum hemorrhage by causing uterine contractions. It is not used to treat hypotension caused by epidural anesthesia.
Choice B rationale
Epoetin is a medication used to treat anemia by stimulating the production of red blood cells. It is not used to treat hypotension caused by epidural anesthesia.
Choice C rationale
Adrenaline (epinephrine) is used in emergency situations to treat severe allergic reactions, cardiac arrest, and severe asthma attacks. It is not the first-line treatment for hypotension caused by epidural anesthesia.
Choice D rationale
Ephedrine is a medication used to treat hypotension caused by epidural anesthesia. It increases blood pressure by stimulating the release of norepinephrine and improving cardiac output.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.