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?

Decrease the rate of IV fluids.

Perform fetal scalp stimulation.

Administer oxygen via a face mask.

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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Correct Answer is D

Explanation

Choice A rationale:
Placing the client in a semi-Fowler’s position for 1 hr after administration is not necessary.
Choice B rationale:
Allowing the medication to reach room temperature prior to administration is not necessary.
Choice C rationale:
Instructing the client to avoid urinary elimination until after administration is not necessary.
Choice D rationale:
Verifying that informed consent is obtained prior to administration is crucial as it ensures the client is aware of the procedure and its potential risks.

A. WBC count 9,000/mm. B. Uterine tenderness. C. Scant lochia. D. Temperature 37.4° C (99.3° F).

Correct Answer is B

Explanation

Choice A rationale:
A WBC count of 9,000/mm is within the normal range (4,500-11,000/mm).
Choice B rationale:
Uterine tenderness is a common symptom of endometritis.
Choice C rationale:
Scant lochia is not typically associated with endometritis.
Choice D rationale:
A temperature of 37.4° C (99.3° F) is within the normal range.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?

Correct Answer is D

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Correct Answer is B

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