A nurse is caring for a client who is in active labor.
The nurse notes late decelerations in the fetal heart rate on the monitor tracing. Which of the following actions should the nurse take first?
Initiate internal fetal heart rate monitoring.
Assist the client to a left lateral position.
Palpate the client's uterus for tachysystole.
Increase the infusion rate of the maintenance IV fluid.
The Correct Answer is B
Choice A rationale
Initiating internal fetal heart rate monitoring is an invasive procedure that is not the priority for a non-reassuring fetal heart rate pattern like late decelerations, which often indicate uteroplacental insufficiency. The first step involves non-invasive intrauterine resuscitation measures to immediately improve fetal oxygenation before considering invasive monitoring, unless the external tracing is inadequate.
Choice B rationale
Late decelerations are an indication of uteroplacental insufficiency (decreased blood flow/oxygen to the fetus during the contraction). Assisting the client to a left lateral position is the priority nursing action because it relieves pressure from the gravid uterus on the vena cava, which in turn maximizes venous return to the heart and increases blood flow and oxygen delivery to the placenta and fetus.
Choice C rationale
While uterine tachysystole (excessive frequency of contractions, greater than five in 10 minutes over 30 minutes) can cause late decelerations, palpating for it is not the absolute first action. The immediate priority is to improve fetal oxygenation by repositioning the mother. Palpation for tachysystole, however, is a quick assessment that should follow the repositioning intervention.
Choice D rationale
Increasing the infusion rate of the maintenance IV fluid (an IV fluid bolus) is a critical step in intrauterine resuscitation for late decelerations. It increases maternal blood volume, which can improve placental perfusion. However, repositioning the client is generally the most immediate, least invasive, and first step to correct or improve the blood flow to the placenta and fetus.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Subconjunctival hemorrhage is a common, generally benign finding in newborns, often resulting from increased intraocular pressure during the birthing process, causing rupture of superficial capillaries in the sclera. It presents as a bright red patch under the conjunctiva and usually resolves spontaneously within a few weeks without intervention, thus it does not warrant immediate, priority assessment.
Choice B rationale
Rust-stained urine, or pink-tinged urine, in a newborn is typically due to the presence of uric acid crystals (urates) in the urine, a normal finding related to concentrated urine and the immaturity of the newborn kidney's ability to concentrate urine fully. This is a common, non-pathological observation in the first few days of life, indicating mild dehydration, but it is not an acute, high-priority concern.
Choice C rationale
Nasal flaring is a significant sign of respiratory distress in a newborn, indicating the infant is attempting to increase the diameter of the nasal passages to decrease airway resistance and enhance the intake of oxygen. This compensatory mechanism suggests compromised gas exchange and potential hypoxemia, requiring immediate assessment and intervention to prevent further respiratory compromise.
Choice D rationale
Overlapping suture lines, also known as molding, occurs when the cranial bones shift and overlap during passage through the narrow birth canal. This is a normal, expected finding, especially after a vaginal delivery, and the shape of the head typically returns to normal within a few days to a week, posing no immediate threat to the newborn.
Correct Answer is C
Explanation
Choice A rationale
Although antiviral medications such as acyclovir or valacyclovir can suppress viral replication and reduce the frequency, duration, and severity of outbreaks, they do not eliminate the virus from the body. Genital herpes simplex virus (HSV-2) infection is a chronic, lifelong condition for which there is currently no known cure, therefore, medication will only manage the symptoms.
Choice B rationale
Genital herpes simplex virus (HSV-2) can be transmitted vertically from mother to fetus or newborn, particularly during a primary infection in pregnancy or during vaginal birth. Neonatal herpes infection can be severe or fatal, causing disseminated disease, central nervous system involvement, or mucocutaneous lesions, thus, it is a significant risk to the developing fetus/newborn.
Choice C rationale
The risk of neonatal transmission of HSV-2 is significantly higher (around 25.
Choice D rationale
Wearing tight-fitting undergarments can increase heat and moisture in the genital area, leading to friction and irritation of the lesions, which can prolong healing and increase discomfort during an outbreak. Clients are advised to wear loose-fitting cotton undergarments to keep the area dry and promote air circulation, which helps with lesion healing.
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