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 A
Explanation
Choice A rationale
Squatting and pelvic lunges are natural positions and exercises that can help with labor progression, but they are not medically recognized methods for inducing labor. These activities may help move the baby into a better position but do not stimulate contractions effectively for labor induction.
Choice B rationale
Amniotomy involves the intentional rupture of the amniotic sac to release amniotic fluid. This procedure can stimulate uterine contractions and is a common method used to induce labor when conditions are appropriate.
Choice C rationale
Oxytocin is a hormone that stimulates uterine contractions. It is commonly administered intravenously to induce or augment labor, making it an effective and widely used method for labor induction.
Choice D rationale
Dinoprostone is a prostaglandin used to ripen the cervix and induce labor. It is applied either as a vaginal insert or gel and helps soften and dilate the cervix, preparing it for labor.
Correct Answer is A
Explanation
Choice A rationale
Reassuring the patient that she will deliver vaginally is inappropriate and could be misleading, especially if there are complications such as placental abruption or severe pre-eclampsia, which may necessitate a cesarean delivery for the safety of the mother and baby.
Choice B rationale
Inserting an indwelling Foley catheter is a standard procedure to monitor urine output and kidney function, especially in cases of pre-eclampsia, where accurate monitoring of fluid balance is crucial.
Choice C rationale
Initiating IV therapy with Lactated Ringer's solution is important to maintain maternal hydration and electrolyte balance, especially if the client is experiencing blood loss and is at risk of hypovolemia.
Choice D rationale
Monitoring the fetal heart tracing is essential to assess the baby's well-being. Continuous fetal monitoring helps detect signs of fetal distress, allowing for timely interventions to ensure the safety of both mother and baby.
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