A nurse is caring for a client who is receiving oxytocin and notes that the electronic fetal monitor shows persistent late decelerations. Which of the following actions should the nurse take?
Increase the rate of the oxytocin infusion.
Administer dinoprostone transvaginally
Place the client in a lateral position.
Assist the client to empty their bladder.
The Correct Answer is C
Rationale:
A. Increase the rate of the oxytocin infusion: Increasing oxytocin would intensify uterine contractions, which can worsen uteroplacental insufficiency and exacerbate late decelerations. This action is unsafe and contraindicated when late decelerations are present.
B. Administer dinoprostone transvaginally: Dinoprostone is used to ripen the cervix or induce labor, not to correct fetal distress caused by uteroplacental insufficiency. Administering it in this scenario would not address the underlying problem and could increase fetal risk.
C. Place the client in a lateral position: Lateral positioning improves uteroplacental blood flow and oxygen delivery to the fetus, which can reduce late decelerations. It is an immediate, safe, and effective nursing intervention to relieve fetal stress caused by decreased placental perfusion.
D. Assist the client to empty their bladder: While bladder distention can affect uterine contractions and comfort, it does not directly address late decelerations. Emptying the bladder may be beneficial for other reasons, but repositioning the client takes priority in improving fetal oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Why did this happen to me?": This statement reflects the anger stage of grief, where the client questions fairness and expresses frustration about their situation. It does not involve negotiating or making promises in exchange for a desired outcome.
B. "I never did anything bad to hurt anyone": This reflects the guilt or depression stage, as the client may be feeling remorse or self-blame related to their illness. It is an emotional expression rather than an attempt to bargain.
C. "I hope my family can accept what's happening": This reflects the acceptance stage, where the client begins to come to terms with their prognosis and focuses on reconciliation or emotional resolution.
D. "If I get better I will study to become a priest.": This is an example of the bargaining stage, where the client attempts to negotiate or make promises in exchange for a desired outcome, such as improved health or extended life. It demonstrates the “what if” reasoning characteristic of this stage of grief.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
Rationale:
- Prenatal anemia: Anemia reduces immune function and tissue oxygenation, making the client more susceptible to postpartum infections, including uterine and systemic infections.
- High parity: Multiparity increases the risk of uterine atony due to repeated stretching and decreased tone of the uterine muscles. This predisposes the postpartum client to poor uterine contraction and increased risk of hemorrhage.
- Polyhydramnios: Excessive amniotic fluid causes uterine overdistension, which weakens uterine contractility and increases the risk of atony and postpartum hemorrhage.
- Prolonged rupture of membranes: Extended rupture of membranes (>18 hours) significantly increases the risk of intrauterine or postpartum infection, including endometritis, due to ascending bacteria from the vaginal canal. This can lead to fever, leukocytosis, and foul-smelling lochia.
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