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A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take?

A.

Decrease the rate of IV fluids.

B.

Perform fetal scalp stimulation.

C.

Administer oxygen via a face mask.

D.

Elevate the client's head.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Decreasing the rate of IV fluids would not address the issue of late decelerations, which indicate fetal hypoxia.

Choice B rationale:
Fetal scalp stimulation is used to assess fetal well-being, but it would not address the issue of late decelerations.
Choice C rationale:
Administering oxygen via a face mask can increase the amount of oxygen available to the fetus, potentially alleviating the hypoxia causing the late decelerations.
Choice D rationale:
Elevating the client’s head would not address the issue of late decelerations.
 


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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

  • Color: Consistent with genetic background

    • Interpretation: B) Sign of potential improvement
    • Rationale: The newborn’s color being consistent with their genetic background indicates a normal adjustment and is not a sign of deterioration. This suggests improvement from the initial condition of acrocyanosis.

  • Axillary Temperature: 36.3°C (97.4°F)

    • Interpretation: B) Sign of potential improvement
    • Rationale: The axillary temperature is within the normal range (36.1°C to 37.2°C), which is a positive sign and suggests that the newborn is maintaining normal body temperature.

  • Reflex Irritability: Cry

    • Interpretation: B) Sign of potential improvement
    • Rationale: A good cry indicates normal reflex irritability and is a positive sign of neurological and overall well-being.

  • Muscle Tone: Flaccid

    • Interpretation: C) Sign of potential worsening condition
    • Rationale: Flaccid muscle tone is concerning as it might indicate a worsening condition or potential neurological issues. It is less typical for muscle tone to be flaccid after the initial adjustment period.

  • Respiration Effort: Good cry

    • Interpretation: B) Sign of potential improvement
    • Rationale: A good cry indicates effective respiration and is a positive sign of the newborn’s respiratory status.

  • Heart Rate: 140/min

    • Interpretation: B) Sign of potential improvement
    • Rationale: The heart rate is within the normal range for newborns (120-160/min), indicating that the cardiovascular system is functioning properly.

Correct Answer is B

Explanation

Choice A rationale:
Misoprostol is not typically used for preeclampsia management. It’s used for cervical ripening and labor induction.
Choice B rationale:
Assessing for edema is important in a client with preeclampsia as it can indicate a worsening condition.
Choice C rationale:
Restricting daily oral fluid intake is not typically part of the management plan for preeclampsia without severe features.
Choice D rationale:
Administering an IV bolus of lactated Ringer’s is not typically part of the management plan for preeclampsia without severe features.

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