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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
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
Correct Answer is B
Explanation
A. "I should avoid breastfeeding for 2 weeks following the immunization."
This statement is incorrect. There is no need to avoid breastfeeding after receiving the rubella vaccine. Breastfeeding is safe and not contraindicated following immunization with the rubella vaccine. Breastfeeding can continue as usual without interruption.
B. "I should avoid becoming pregnant for at least 1 month following the immunization."
This statement is correct. Following administration of the rubella vaccine, it is recommended to avoid becoming pregnant for at least 1 month. This precaution is due to theoretical concerns about the vaccine potentially affecting the developing fetus if a woman were to become pregnant shortly after vaccination. Rubella infection during pregnancy can cause serious birth defects, so it's important to take precautions to avoid potential harm to the fetus.
C. "I will report joint pain that develops after the immunization to my provider immediately."
While joint pain can be a rare side effect of the rubella vaccine, it is not typically necessary to report it immediately unless it is severe or persistent. Mild joint pain is a common and expected side effect of some vaccines, including the rubella vaccine, and typically resolves on its own without intervention. However, if joint pain is severe or persistent, it may be appropriate to report it to a healthcare provider for further evaluation and management.
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