A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse
take first?
Turn the client onto her side.
Increase the client's IV fluid infusion rate.
Administer oxygen to the client.
Palpate the client's uterus.
The Correct Answer is A
Choice A:The priority action when the fetal monitor tracing shows late decelerations after the client's membranes rupture is to turn the client onto her side. This position change helps relieve pressure on the vena cava and improves blood flow to the fetus.
Choice B: Increasing the client's IV fluid infusion rate is not the first priority in this situation, as late decelerations are primarily related to uteroplacental insufficiency rather than maternal hydration status.
Choice C: Administering oxygen to the client is important, but turning the client onto her side should be the first action to improve fetal oxygenation.
Choice D: Palpating the client's uterus is not the first priority in the presence of late
decelerations. The focus should be on relieving the compression on the vena cava and improving fetal oxygenation by changing the client's position.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "The test will be performed if your baby's heartbeat is heard."
Incorrect: Amniocentesis is not typically performed based on whether the baby's heartbeat is heard. It is done for specific diagnostic purposes, such as genetic testing or assessing certain fetal conditions.
B. "This test will determine if your baby's lungs are mature."
Incorrect: Amniocentesis does not determine fetal lung maturity. The test involves the extraction of a small amount of amniotic fluid to analyze fetal chromosomes and identify genetic conditions.
C. "After the test, you will be given Rh immune globulin since you are Rh positive."
Incorrect: Rh immune globulin (Rhogam) is given to Rhnegative pregnant women to prevent Rh sensitization, which occurs when an Rhnegative mother is exposed to
Rhpositive fetal blood. Rhogam is not directly related to amniocentesis.
D. "This test requires the presence of an adequate volume of amniotic fluid."
Correct: Amniocentesis requires a sufficient amount of amniotic fluid around the fetus for safe and accurate testing. If there is not enough amniotic fluid, the procedure may be postponed or canceled.
Correct Answer is D
Explanation
A: Elevated temperature during labor may be common and is not the nurse's first priority, especially when the client is receiving epidural analgesia, as it can be related to the stress of labor or other factors.
B: Reduced sensation of the lower extremities is an expected effect of epidural analgesia, and it is not the nurse's first priority unless it leads to complications such as motor weakness or respiratory distress.
C: Generalized itching is a common side effect of epidural analgesia due to opioids, and it can be managed with interventions such as antihistamines. However, it is not the nurse's first priority unless it is severe or accompanied by other concerning symptoms.
D: Epidural analgesia can cause vasodilation and decrease the client's blood pressure, which can lead to hypotension. Hypotension can be detrimental to both the mother and the baby and requires immediate attention to prevent complications. Therefore, the nurse's first priority is to address the low blood pressure.
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