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 A
Explanation
Choice A rationale
A weak cough, inability to talk, and grasping the throat are classic signs of a severe airway obstruction. The Heimlich maneuver, or abdominal thrusts, is the recommended intervention for conscious adults and children experiencing a severe foreign body airway obstruction. It increases intrathoracic pressure to expel the obstruction, restoring airflow and preventing anoxic injury.
Choice B rationale
Slapping the client on the back is not the primary intervention for a conscious adult with a severe airway obstruction and may actually worsen the situation by dislodging the object further into the airway. Back blows are generally recommended for infants or as an alternative for conscious choking victims when abdominal thrusts are not feasible.
Choice C rationale
Assisting the client to the floor and initiating mouth-to-mouth resuscitation is inappropriate when the client is still conscious and has an airway obstruction. Resuscitation efforts are indicated for unresponsive individuals who are not breathing or are only gasping. The priority here is to clear the airway obstruction while the person is still conscious.
Choice D rationale
Observing the client before taking further action is dangerous and could lead to rapid deterioration and loss of consciousness. A severe airway obstruction is a medical emergency requiring immediate intervention. Delaying action significantly increases the risk of hypoxia, brain damage, and cardiac arrest, making prompt and decisive action crucial.
Correct Answer is ["A","C","F"]
Explanation
Choice A rationale
Post-kidney transplant, immunosuppressive medications are crucial to prevent rejection, which also compromises the immune system. Engaging in contact sports significantly increases the risk of direct trauma to the transplanted kidney, potentially causing injury or rupture, which could necessitate re-transplantation or lead to graft loss.
Choice E rationale
Grapefruit contains furanocoumarins, compounds that inhibit the cytochrome P450 3A4 (CYP3A4) enzyme system in the liver and intestines. Many immunosuppressants, like calcineurin inhibitors (e.g., cyclosporine, tacrolimus), are metabolized by CYP3A4. Inhibition of this enzyme can lead to increased drug concentrations and elevated risk of toxicity.
Choice F rationale
Fluid restriction post-kidney transplant may be necessary, particularly in the immediate postoperative period or if the patient experiences fluid overload or delayed graft function. Excessive fluid intake could contribute to hypertension or pulmonary edema, complicating recovery and potentially stressing the newly transplanted kidney.
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