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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Irregular contractions of 10 to 20 seconds in duration that are not felt by the client during a nonstress test may indicate a need for further diagnostic testing. These could be Braxton Hicks contractions, which are normal, but if they become regular and increase in intensity, they could indicate preterm labor.
Choice B rationale
An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period is a normal finding on a nonstress test. This is known as a reactive nonstress test and indicates that the fetus is well-oxygenated.
Choice C rationale
No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period is a normal finding on a nonstress test. Late decelerations can indicate fetal hypoxia.
Choice D rationale
Three fetal movements perceived by the client in a 20-min testing period is a normal finding on a nonstress test. Fetal movement is a positive sign of fetal well-being.
Correct Answer is []
Explanation
• Neonatal hypoglycemia: The newborn’s blood glucose level is 30 mg/dL, which is below the normal range. This, along with the jitteriness, weak cry, and mottled skin with acrocyanosis, suggests the newborn is most likely experiencing neonatal hypoglycemia.
• Actions to take: The nurse should administer a 10% dextrose IV bolus as prescribed by the provider to increase the newborn’s blood glucose levels. The nurse should also monitor the newborn’s blood glucose levels every 30 minutes to ensure they are increasing towards the normal range.
• Parameters to monitor: The nurse should monitor the newborn’s blood glucose levels to ensure they are increasing towards the normal range. The nurse should also monitor the newborn’s heart rate, as tachycardia can be a sign of hypoglycemia. If the newborn’s condition does not improve or worsens, the nurse should notify the healthcare provider immediately.
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