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.

Elevate the client’s head.

Perform fetal scalp stimulation.

Administer oxygen via a face mask.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Decreasing the rate of IV fluids would not address the issue of late decelerations, which are a sign of fetal hypoxia.
Choice B rationale
Elevating the client’s head would not address the issue of late decelerations.
Choice C rationale
Performing fetal scalp stimulation is used to assess fetal well-being when the tracing is nonreactive, not when late decelerations are present.

Choice D rationale
Administering oxygen via a face mask is the correct answer. This increases maternal oxygen saturation, which can help increase oxygen delivery to the fetus.

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Correct Answer is A

Explanation

Choice A rationale
Assessing for edema is an important action for the nurse to take when caring for a client who is 1 hr postpartum and has preeclampsia without severe features. Edema can be a sign of worsening preeclampsia.
Choice B rationale
Administering an IV bolus of lactated Ringer’s is not typically necessary for a client with preeclampsia without severe features.
Choice C rationale
Obtaining a prescription for misoprostol is not relevant in this context. Misoprostol is a medication used to induce labor or treat postpartum hemorrhage, not preeclampsia.
Choice D rationale
Assisting the client with food intake is not directly related to the management of preeclampsia

Correct Answer is []

Explanation

Condition: The client is most likely expeíiencing Placenta píevia. This condition is chaíacteíized by painless, bíight íed vaginal bleeding duíing the thiíd tíimesteí, which matches the client’s symptoms.
Actions:

1. Instíuct the client to maintain bed íest: This can help to píevent fuítheí bleeding.
2. Píepaíe the client foí a possible ultíasound: An ultíasound can help to confiím the diagnosis and assess the placental location and fetal well-being.

Paíameteís to Monitoí:

1. Ïetal heaít íate: Monitoíing the fetal heaít íate can help to assess the baby’s well-being.
2. Hemoglobin and hematocíit levels: These should be monitoíed to assess the client’s blood loss and íisk of anemia.

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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

A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features. What actions should the nurse plan to take?

Correct Answer is A

Explanation

Correct Answer is []

Explanation

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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?