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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Postpartum hemorrhage: Effacement and dilation relate to the progress of labor, not postpartum hemorrhage. Postpartum hemorrhage is excessive bleeding that occurs after childbirth, typically within 24 hours, and can have various causes unrelated to cervical dilation.

B. Incompetent cervix: Incompetent cervix, also known as cervical insufficiency, refers to the premature and painless dilation of the cervix during the second trimester of pregnancy. It is not directly related to the dilation mentioned in the scenario. However, it is possible that the client may have misunderstood the timing of contractions, and the nurse should assess for other signs of cervical insufficiency.

C. Hyperemesis gravidarum: Hyperemesis gravidarum is severe nausea and vomiting during pregnancy, which can lead to dehydration and electrolyte imbalances. It is not directly related to cervical dilation or effacement.

D. Ectopic pregnancy: An ectopic pregnancy is a pregnancy that occurs outside the uterus, usually in the fallopian tube. Cervical dilation and effacement are not associated with ectopic pregnancies.

A. The client’s fundus is firm and midline B. The client’s umbilical cord lengthens C. The client reports a feeling of vaginal fullness D. The client saturates a perineal pad in 1 hr.

Correct Answer is A

Explanation

A. The client’s fundus is firm and midline: Oxytocin is commonly administered in the third stage of labor to promote uterine contraction and prevent postpartum hemorrhage. A therapeutic effect of oxytocin is the firm and midline positioning of the uterus, indicating effective contraction and the prevention of excessive bleeding.

B. The client’s umbilical cord lengthens: The lengthening of the umbilical cord is not an expected therapeutic effect of oxytocin administration. Oxytocin primarily affects uterine contractions.

C. The client reports a feeling of vaginal fullness: A feeling of vaginal fullness is not a typical therapeutic effect of oxytocin administration. It may be associated with other factors, such as the presence of blood clots or retained placental fragments, and should be further assessed.

D. The client saturates a perineal pad in 1 hour: Saturating a perineal pad in 1 hour is not an expected therapeutic effect of oxytocin. Excessive bleeding or saturation of perineal pads may be a sign of postpartum hemorrhage and requires immediate attention.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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