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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Weak cry: A weak cry is not a specific manifestation associated with newborns exposed to methadone. Methadone-exposed newborns may show signs of neonatal abstinence syndrome (NAS), but a weak cry is not a primary characteristic.
B. Poor feeding: This is the correct answer. Poor feeding is a common manifestation of neonatal abstinence syndrome (NAS) in newborns exposed to opioids, including methadone. NAS can cause gastrointestinal symptoms, including feeding difficulties.
C. Respiratory rate of 30/min: While respiratory issues can be part of the neonatal abstinence syndrome, a specific respiratory rate of 30/min is not universally characteristic. NAS symptoms can vary among infants.
D. Absent Moro reflex: The Moro reflex is not typically affected in infants exposed to methadone. NAS symptoms often involve central nervous system irritability, but the Moro reflex is a complex primitive reflex that may remain intact.
Correct Answer is A
Explanation
A. Yellowed sclera : Yellowed sclera (the white part of the eyes) can indicate jaundice in a newborn. Jaundice is caused by elevated levels of bilirubin and may signify various underlying conditions, including an excessive breakdown of red blood cells, liver immaturity, or other issues. Prompt notification of the healthcare provider is necessary to evaluate and manage jaundice appropriately.
B. Stooling after each breastfeeding: Stooling after each breastfeeding session is a common and expected occurrence in newborns. Breastfed babies often pass stools frequently, and this is generally not a cause for concern unless there are other associated symptoms.
C. Intermittent crossing of eyes: Occasional intermittent crossing of eyes can be normal in newborns. However, if persistent or accompanied by other concerning signs, it might require evaluation, but it's not typically an immediate concern.
D. Voids eight to ten times per day: A healthy newborn typically voids frequently throughout the day. Eight to ten times per day is within the expected range for a newborn's urinary output and might not be a cause for immediate concern.
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