A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor.
Which of the following is the first action the nurse should take?
Apply fetal scalp electrode.
Perform a vaginal exam.
Insert an intravenous catheter.
Assist the client into the left-lateral position.
The Correct Answer is D
Choice A rationale
Applying a fetal scalp electrode is an invasive procedure that provides a more accurate assessment of fetal heart rate. However, late decelerations indicate uteroplacental insufficiency requiring immediate interventions to improve fetal oxygenation before considering invasive monitoring.
Choice B rationale
Performing a vaginal exam can assess labor progress and rule out cord prolapse or other issues. While important, it is not the immediate priority when late decelerations indicate acute fetal hypoxemia; improving oxygenation to the fetus is paramount.
Choice C rationale
Inserting an intravenous catheter is essential for administering fluids or medications. However, the most immediate intervention for late decelerations is to improve uterine blood flow and fetal oxygenation, which is achieved through maternal repositioning as the first step.
Choice D rationale
Late decelerations indicate uteroplacental insufficiency, meaning reduced blood flow and oxygen to the fetus. Repositioning the client to the left-lateral position relieves pressure on the vena cava, improving venous return to the heart, thus increasing uterine blood flow and fetal oxygenation by optimizing placental perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A rationale
This statement is inaccurate because leadership inherently involves guiding individuals and teams towards achieving organizational objectives and getting work done. Effective leaders inspire action and commitment, which directly contributes to productivity and goal attainment, even though their approach differs from management's direct task orientation.
Choice B rationale
Leadership is indeed more focused on people. It involves inspiring, motivating, and empowering individuals to achieve shared goals. This human-centric approach fosters collaboration, innovation, and personal growth within the team, contrasting with management's primary focus on tasks and operational processes.
Choice C rationale
While management does involve budget allocation and financial oversight as part of its planning and controlling functions, this is not its sole or defining focus. Management encompasses a broader range of responsibilities including organizing resources, directing personnel, and controlling operations to achieve specific objectives.
Choice D rationale
Management is typically an assigned position within an organizational hierarchy, granting formal authority and responsibility for specific functions or departments. This contrasts with leadership, which can emerge organically within a group regardless of formal title, based on influence and inspiration.
Correct Answer is ["56"]
Explanation
Step 1 is: Calculate the total minutes the IV needs to run. 2 hours × 60 minutes/hour = 120 minutes.
Step 2 is: Calculate the mL/minute rate. 450 mL ÷ 120 minutes = 3.75 mL/minute.
Step 3 is: Calculate the gtt/minute rate. 3.75 mL/minute × 15 gtt/mL = 56.25 gtt/minute. The current IV rate is 56 gtt/minute.
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