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 ["A","C","D","E","F","G","I","J"]

Explanation

Heart rate 110/min
Correct (requires follow-up) – A heart rate of 110/min is elevated, which could indicate dehydration or other physiological stress, such as hyperemesis gravidarum.
Blood pressure 104/66 mm Hg
Wrong (does not require follow-up) – This blood pressure is within normal limits, particularly in pregnancy, where slight decreases in blood pressure are common.
Hemoglobin 10.2 g/dL
Correct (requires follow-up) – This is lower than the normal range (11 to 16 g/dL) and indicates mild anemia, which should be monitored during pregnancy.
Potassium 3.3 mEq/L
Correct (requires follow-up) – This potassium level is below the normal range (3.5 to 5 mEq/L), indicating hypokalemia, likely due to vomiting. Hypokalemia needs correction as it can cause complications.
BUN 28 mg/dL
Correct (requires follow-up) – Blood urea nitrogen (BUN) is elevated (normal range 10 to 20 mg/dL), which could indicate dehydration, a concern especially with vomiting and reduced intake.
Urine specific gravity 1.045
Correct (requires follow-up) – This is higher than the normal range (1.005 to 1.03), suggesting concentrated urine and potential dehydration.
Decreased skin turgor
Correct (requires follow-up) – Decreased skin turgor is a physical sign of dehydration and should be addressed, especially considering the client's vomiting.
WBC count 7,500/mm3
Wrong (does not require follow-up) – The WBC count is within the normal range (5,000 to 10,000/mm3), so it does not indicate an infection or other abnormalities.
Client reports vomiting several times a day over the last 2 weeks
Correct (requires follow-up) – Persistent vomiting over this time period is concerning for hyperemesis gravidarum and could lead to complications such as dehydration and electrolyte imbalances.
Urine color dark amber
Correct (requires follow-up) – Dark amber urine could be a sign of dehydration, especially in combination with an elevated urine specific gravity.

A. Weight loss of 3% B. Voided one time since birth C. Central cyanosis D. Apical pulse rate of 156/min

Correct Answer is C

Explanation

A. Weight loss of 3%:

Newborns commonly experience weight loss in the first few days of life due to factors such as loss of excess fluid and adjustment to feeding. A weight loss of up to 7-10% in the first week is considered normal. Therefore, a weight loss of 3% alone, while notable, is not typically concerning enough to require immediate intervention. However, it should be monitored closely to ensure that the newborn is receiving adequate nutrition and hydration.

B. Voided one time since birth:

Newborns typically pass urine within the first 24 hours after birth. However, the frequency of voiding can vary, and it is not uncommon for a newborn to void only once in the first 24 hours. While it is important for newborns to void regularly to ensure adequate hydration and renal function, voiding once in the first 24 hours may not necessarily indicate a problem, especially if the newborn is breastfeeding. Therefore, while this finding should be monitored, it may not require immediate intervention.

C. Central cyanosis:

Central cyanosis, characterized by bluish discoloration of the lips, tongue, and mucous membranes, indicates inadequate oxygenation of the blood. It suggests a potential respiratory or cardiac problem that requires immediate evaluation and intervention to ensure adequate oxygenation and prevent complications. Central cyanosis is a concerning finding in newborns and warrants prompt attention from healthcare providers to determine the underlying cause and initiate appropriate treatment.

D. Apical pulse rate of 156/min:

The normal range for a newborn's heart rate is typically 120-160 beats per minute. An apical pulse rate of 156/min falls within this range and is not necessarily indicative of a problem, especially if the newborn is active or crying. While variations in heart rate can occur, a rate of 156/min alone may not be alarming. However, it should be monitored for any changes or trends outside the normal range as part of routine newborn assessment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","D","E","F","G","I","J"]

Explanation

A nurse is reviewing the medical record of a newborn who is 24 hr old. Which of the following findings requires intervention?

Correct Answer is C

Explanation

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