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 B

Explanation

Choice A: Bowel prep protocols are not required for an amniocentesis procedure, as it involves sampling amniotic fluid from the uterus, not the bowel.
Choice B: Emptying the bladder before the procedure is important to improve comfort and minimize the risk of accidental puncture during the amniocentesis.

Choice C: It is essential to have a full bladder for some ultrasound procedures, but it is not necessary for an amniocentesis. A full bladder can help push the uterus upward and make it easier to visualize the fetus during the ultrasound, but it is not relevant to the amniocentesis procedure.
Choice D: Washing the abdomen with soap and water is not a required step for an amniocentesis procedure. The procedure involves sterile preparation of the abdomen using an antiseptic
solution.

A. Administer a 500 mL bolus of 5% dextrose in water prior to the epidural administration. B. Inform the client that the anesthetic effect will last for approximately 6 hours. C. Obtain a 30 min electronic fetal monitoring (EFM) strip and prepare to give a bolus of Lactated Ringers solution prior to the epidural administration. D. Have the client stand very still at the bedside with her arms at her side.

Correct Answer is C

Explanation

A: Administering a 500 mL bolus of 5% dextrose in water is not necessary before the epidural administration, and it may not be recommended in active labor as it can increase the risk of fluid overload.

B: The duration of the anesthetic effect of the epidural can vary depending on the medication used, and it is not the nurse's priority during the preparation process.

C: Prior to administering epidural analgesia, the nurse should obtain a 30minute electronic fetal monitoring (EFM) strip to assess the fetal heart rate and monitor for any signs of fetal distress during the procedure.

D: Having the client stand very still with her arms at her side is not practical or necessary for epidural administration and could be uncomfortable for the client 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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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?