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 ["-2"]
Explanation
Step 1 is to calculate the change in blood pressure. Change in systolic blood pressure = 148 mm Hg - 130 mm Hg = 18 mm Hg. Change in diastolic blood pressure = 88 mm Hg - 80 mm Hg = 8 mm Hg.
Step 2 is to calculate the change in weight. Change in weight = 44.5 kg - 42.2 kg = 2.3 kg.
Step 3 is to calculate the change in pulse oximetry. Change in pulse oximetry = 98% - 100% = -2%.
Correct Answer is ["9.5"]
Explanation
Step 1 is: Calculate the total units in 1 mL. 25,000 units ÷ 250 mL = 100 units/mL.
Step 2 is: Calculate the mL/hour. 950 units/hr ÷ 100 units/mL = 9.5 mL/hr. The infusion pump would be set at 9.5 mL/hr.
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