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?

Perform fetal scalp stimulation

Administer oxygen via a face mask.

Elevate the client's head.

Decrease the rate of IV fluids.

Answer and Explanation

The Correct Answer is B

A. Perform fetal scalp stimulation:

Fetal scalp stimulation involves applying pressure to the fetal scalp during a vaginal examination to elicit a response from the fetus, such as an acceleration of the fetal heart rate. While this can provide additional information about fetal well-being, it is not the initial priority when late decelerations are observed on the fetal monitor. The focus should first be on interventions aimed at improving fetal oxygenation to address the underlying cause of the late decelerations.

B. Administer oxygen via a face mask:

Administering oxygen to the mother is a priority intervention when late decelerations of the fetal heart rate are observed on the external fetal monitor. Late decelerations often indicate uteroplacental insufficiency, where the fetus is not receiving adequate oxygenation. Administering oxygen to the mother helps increase oxygen levels in her blood, improving oxygen delivery to the fetus and potentially mitigating the effects of uteroplacental insufficiency.

C. Elevate the client's head:

Elevating the client's head is not indicated when late decelerations are observed. This position could potentially compromise maternal-fetal circulation by reducing blood flow to the placenta. Maintaining a side-lying or semi-Fowler's position is often recommended to improve blood flow to the placenta and enhance fetal oxygenation.

D. Decrease the rate of IV fluids:

Adjusting the rate of IV fluids may be considered in some situations, such as if there is evidence of fluid overload or if the mother is receiving excessive amounts of IV fluids. However, it is not typically the initial intervention for addressing late decelerations. The focus should first be on interventions aimed at improving maternal-fetal oxygenation, such as administering oxygen and positioning the client appropriately.

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Correct Answer is D

Explanation

Explanation:

A. Airborne precautions:

Airborne precautions are used for pathogens that are transmitted through the air over long distances. This includes pathogens such as Mycobacterium tuberculosis (TB) or varicella-zoster virus (chickenpox). However, Clostridium difficile (C. difficile) infection is not transmitted through the airborne route. Therefore, airborne precautions are not appropriate for managing C. difficile infection.

B. Droplet precautions:

Droplet precautions are used for pathogens that are transmitted through respiratory droplets, typically over short distances (usually within about 3 feet). This includes pathogens such as influenza virus or Bordetella pertussis (whooping cough). However, C. difficile infection is primarily transmitted through the fecal-oral route and contact with contaminated surfaces or objects, rather than through respiratory droplets. Therefore, droplet precautions are not appropriate for managing C. difficile infection.

C. Protective environment:

Protective environment, also known as reverse isolation, is used to protect immunocompromised clients from pathogens in the environment. This includes clients who have undergone bone marrow transplantation or chemotherapy. However, protective environment precautions are not appropriate for managing C. difficile infection. C. difficile infection control measures primarily focus on preventing the spread of the infection to others, rather than protecting the client from external pathogens.

D. Contact precautions:

Contact precautions are used for pathogens that are transmitted through direct or indirect contact with the client or their environment. This includes pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) or C. difficile. C. difficile infection is primarily transmitted through contact with contaminated surfaces or objects. Therefore, contact precautions, which involve measures to prevent the transmission of infectious agents via contact, including wearing gloves and a gown, performing hand hygiene, and ensuring environmental cleaning and disinfection, are appropriate for managing C. difficile infection.

A. Encourage the client to apply a warm pack to the perineum for discomfort. B. Prepare the client for a pudendal nerve block. C. Apply hydrogel pads to the perineum every 4 hr. D. Place a witch hazel pad on the client's perineal pad after each voiding.

Correct Answer is D

Explanation

A. Encourage the client to apply a warm pack to the perineum for discomfort.

While warm packs can provide comfort and promote relaxation for some types of perineal discomfort, they may not be suitable for a third-degree perineal laceration. In fact, applying heat directly to the perineum may exacerbate swelling and increase discomfort in this particular case. Therefore, it is not the most appropriate intervention for this client.

B. Prepare the client for a pudendal nerve block.

A pudendal nerve block is typically used during labor or for specific procedures (such as episiotomy repair) to provide pain relief. It is not a routine intervention for postpartum perineal lacerations.

C. Apply hydrogel pads to the perineum every 4 hr.

While hydrogel pads can provide some relief for perineal discomfort, they are not typically used specifically for third-degree perineal lacerations. These types of lacerations require medical intervention and repair rather than solely relying on over-the-counter remedies like hydrogel pads. Therefore, this intervention may not address the underlying issue effectively.

D. Place a witch hazel pad on the client's perineal pad after each voiding.

Witch hazel pads can provide soothing relief to the perineum and help reduce swelling and discomfort after childbirth. They have a cooling effect and can also have mild astringent properties, which may aid in promoting healing.Placing a witch hazel pad on the perineal pad after each voiding helps ensure that the perineum remains clean and that the client experiences continuous relief from discomfort

Neuropathic Pain: Pudendal Nerve Block | SpringerLink

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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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