A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take?

Prepare for an emergency cesarean birth.

Assist the client to a knee-chest position.

Prepare the client for continuous internal monitoring.

Continue observing the fetal heart rate.

Answer and Explanation

The Correct Answer is D

A. Early decelerations are typically benign and often associated with head compression, not necessitating an emergency cesarean birth.

B. A knee-chest position is generally used for variable decelerations but is not indicated for early decelerations.

C. Continuous internal monitoring may be necessary in certain situations, but in the case of early decelerations, it is not an immediate intervention.

D. Early decelerations usually require continued monitoring without immediate intervention as they typically resolve spontaneously with contractions.

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Correct Answer is A

Explanation

A. Having the client wear a surgical mask while being transported outside the room is essential to prevent the transmission of TB to others. This minimizes exposure to airborne droplets.

B. Wearing a surgical mask while providing care for the client is not sufficient for preventing TB transmission; an N95 respirator is required to protect healthcare workers from inhaling airborne particles.

C. While restricting visitors may help limit exposure, it is not the most effective preventive measure compared to ensuring that the client wears a mask when out of their room.

D. Initiating contact precautions is not necessary for TB, as it primarily requires airborne precautions. Airborne isolation precautions should be followed, including the use of N95 respirators for healthcare workers and appropriate ventilation.

A. Dietary salt restriction B. Absence of symptoms C. Addition of a new medication D. A detailed plan of care

Correct Answer is D

Explanation

A. Dietary salt restriction is challenging but is a specific intervention that can be managed with education and support.

B. The absence of symptoms can significantly hinder compliance because clients may not perceive the need to adhere to a treatment plan if they do not feel unwell. This perception can lead to underestimating the importance of managing their blood pressure.

C. The addition of a new medication may pose some challenges, but clients often adapt to new medications with proper guidance.

D. A detailed plan of care can enhance understanding and compliance, making it less likely to be a barrier compared to the lack of symptomatic cues indicating a need for treatment.

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A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take?

Nursing Test Bank

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Correct Answer is A

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Correct Answer is D

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