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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A: It is not accurate to say that a repeat cesarean birth will always be safer. The decision for a repeat cesarean or a trial of labor after cesarean (TOLAC) depends on various factors, including the client's medical history and the type of incision used in the previous cesarean.

Choice B: While there are multiple factors to consider, the nurse can still provide general information about the possibility of attempting a vaginal birth after cesarean (VBAC).

Choice C: While focusing on the health of the newborn is important, the client's question about the possibility of a future VBAC can be addressed without dismissing her concerns.

Choice D: The type of incision used in the previous cesarean birth (such as low transverse incision) is a significant factor in determining the eligibility for a VBAC in subsequent pregnancies. Clients with certain types of incisions may have a higher likelihood of success with a VBAC.

A. Maintain the client in the lithotomy position. B. Encourage the client to empty her bladder every 2 hr. C. Remind the client to bear down with each contraction. D. Perform vaginal examinations frequently,

Correct Answer is B

Explanation

A. Maintain the client in the lithotomy position: The lithotomy position is not typically

maintained during the active phase of labor. It is used during the pushing stage (second stage) of labor.
B. Encourage the client to empty her bladder every 2 hr: A full bladder can impede fetal descent and progress during labor, so encouraging the client to empty her bladder regularly is essential.
C. Remind the client to bear down with each contraction: Bearing down during the active phase of labor is not appropriate, as it may lead to premature pushing and cervical swelling.
D. Perform vaginal examinations frequently: Frequent vaginal examinations can increase the risk of infection and should be minimized during labor.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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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?