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. Initiating the process to review the medical record is appropriate; clients have the right to access their medical information under HIPAA regulations, and the nurse can assist in starting that process.

B. While there are restricted parts of a medical record, the response lacks a proactive approach to assisting the client in accessing the information they have the right to view.

C. This response is dismissive of the client's request and does not provide an avenue for understanding the medical record better.

D. Although the provider can provide more detailed information about treatment, it does not

A. "I am concerned about my child's future participation in team sports." B. "My child doesn't like to sit still for nebulizer treatments." C. "My child has only a small amount of mucus after percussion therapy." D. "I think that my child has been running a fever over the last couple of days."

Correct Answer is C

Explanation

A. Concerns about participation in team sports may indicate a desire for improved lung function but do not directly necessitate the use of a high-frequency chest compression vest.

B. Discomfort during nebulizer treatments may warrant alternative therapies, but it is not a direct indication for a high-frequency chest compression vest.

C. A small amount of mucus after percussion therapy suggests inadequate airway clearance, which may prompt the need for more effective techniques, such as the high-frequency chest compression vest, to facilitate mucus clearance and improve lung function.

D. A fever indicates a potential infection and requires further assessment but does not directly suggest the need for a high-frequency chest compression vest.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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