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?
Administer oxygen via a face mask
Decrease the rate of IV fluids
perform fetal scalp stimulation
Elevate the client’s head
The Correct Answer is A
A. Administer oxygen via a face mask: This is the correct answer. Administering oxygen helps improve oxygenation to the fetus and is a standard intervention for late decelerations.
B. Decrease the rate of IV fluids: Decreasing IV fluids is not typically the first intervention for late decelerations. The primary goal is to improve oxygenation to the fetus, and increasing or maintaining maternal blood volume is important.
C. Perform fetal scalp stimulation: Fetal scalp stimulation is not the first-line intervention for late decelerations. It is more commonly used for assessing fetal well-being and responsiveness during the labor process.
D. Elevate the client’s head: Elevation of the client's head is not the recommended position for addressing late decelerations. Placing the client in a side-lying position is more appropriate to relieve pressure on the vena cava.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Correct Answer: B
B. Administer broad-spectrum antibiotics
Newborns with a leaking myelomeningocele are at a high risk for infection, especially meningitis, due to the exposure of cerebrospinal fluid (CSF). Administering broad-spectrum antibiotics helps reduce the risk of infection until the defect is surgically closed.
Incorrect answers:
A.Monitor the rectal temperature every 4 hr.Taking rectal temperatures is contraindicated in a newborn with a myelomeningocele due to the risk of trauma to the rectum and potential introduction of bacteria near the exposed spinal cord and CSF. Axillary temperatures should be used instead.
C.Prepare for surgical closure after 72 hr.Surgical repair of a myelomeningocele is typically performed within the first 24–48 hours of life to reduce the risk of infection and prevent further nerve damage.
D.Cleanse the site with povidone-iodine. Povidone-iodine is not appropriate for cleansing the exposed myelomeningocele site because it can be too harsh and toxic to neural tissue.
Correct Answer is B
Explanation
. Protective environment: Protective environment precautions are used for clients with compromised immune systems, such as those undergoing stem cell transplantation. This precaution aims to protect the client from exposure to environmental pathogens.
B. Contact: This is the correct answer. Contact Precautions are appropriate for clients with C. difficile infection. The precautions include using gloves and gowns when entering the room and ensuring proper hand hygiene to prevent the transmission of the bacteria.
C. Droplet: Droplet precautions are used for diseases that are transmitted through respiratory droplets, such as influenza or pertussis. C. difficile is not primarily transmitted through respiratory droplets.
D. Airborne: Airborne precautions are used for diseases that can be transmitted by tiny particles suspended in the air, such as tuberculosis or chickenpox. C. difficile is not transmitted through the airborne route.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today