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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale:
Abdominal distention is not typically a sign of hypoglycemia in a newborn. It could be related to other factors such as feeding issues or gastrointestinal problems.
Choice B rationale:
Jitteriness can be a sign of hypoglycemia in a newborn as low blood sugar can cause nervous system hyperactivity.
Choice C rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a sign of hypoglycemia.
Choice D rationale:
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in a newborn as low blood sugar can affect muscle function.
Choice E rationale:
Temperature instability can be a sign of hypoglycemia in a newborn as low blood sugar can affect the body’s ability to regulate temperature.
Correct Answer is D
Explanation
Choice A rationale:
Breastfeeding is not contraindicated following rubella immunization, so this statement is incorrect.
Choice B rationale:
The rubella vaccine is a single-dose vaccine, not a series of three.
Choice C rationale:
Joint pain can occur following rubella immunization, but it’s not a severe side effect that requires immediate medical attention.
Choice D rationale:
Women are advised to avoid pregnancy for at least 1 month following rubella immunization due to the theoretical risk to the fetus, so this statement is correct.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.