A nurse is caring for a client who is receiving oxytocin for the induction of labor and notes late decelerations of the fetal heart rate on the monitor tracing. The nurse should take which of the following actions?
Administer misoprostol 25 mcg vaginally.
Place the client in a lateral position.
Administer oxygen via a face mask at 2 L/min.
Decrease the maintenance IV solution infusion rate.
The Correct Answer is B
Late decelerations are a type of fetal heart rate (FHR) pattern that indicate fetal hypoxia (lack of oxygen) due to uteroplacental insufficiency (decreased blood flow to the placenta). They are defined as a gradual decrease in FHR that occurs after the peak of a uterine contraction and returns to baseline after the end of the contraction¹. Late decelerations are associated with adverse neonatal outcomes, such as low Apgar scores, acidosis, and neonatal intensive care unit admission².
The nurse should take immediate actions to improve fetal oxygenation and blood flow when late decelerations are detected. The first and most important action is to place the client in a lateral position, either left or right, to reduce compression of the inferior vena cava and increase uterine perfusion. This can improve fetal oxygenation and reduce the severity of late decelerations¹³.
The other actions that the nurse should take are:
- Discontinue oxytocin infusion if it is being used for induction or augmentation of labor, as it can cause uterine tachysystole (excessive contractions) and worsen uteroplacental insufficiency¹³.
- Administer oxygen to the client at 8 to 10 L/min via a nonrebreather face mask to increase maternal oxygen saturation and fetal oxygen delivery¹³.
- Increase intravenous (IV) fluid infusion rate to maintain maternal hydration and blood pressure, which can improve uterine blood flow¹³.
- Notify the provider and prepare for possible operative delivery if late decelerations persist or fetal distress occurs¹³.
- Provide emotional support and reassurance to the client and family, as late decelerations can cause anxiety and fear⁴.
The other options are not actions that the nurse should take:
- a) Administer misoprostol 25 mcg vaginally. This is not correct because misoprostol is a medication that is used to induce labor by ripening the cervix and stimulating contractions. It is not indicated for late decelerations and can cause uterine hyperstimulation and fetal distress⁵.
- c) Administer oxygen via a face mask at 2 L/min. This is not correct because this is too low of an oxygen flow rate to improve fetal oxygenation. The recommended oxygen flow rate for late decelerations is 8 to 10 L/min via a nonrebreather face mask¹³.
- d) Decrease the maintenance IV solution infusion rate. This is not correct because this can cause maternal dehydration and hypotension, which can reduce uterine blood flow and worsen fetal hypoxia. The nurse should increase the IV fluid infusion rate to maintain maternal hydration and blood pressure¹³.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Phototherapy is a treatment method used to reduce high levels of bilirubin in the blood of a newborn with jaundice. During phototherapy, the newborn is exposed to special lights that help break down the bilirubin and allow it to be eliminated from the body. It is important to protect the newborn's eyes during phototherapy.
Option a) Giving the newborn 1 oz of glucose water every 4 hours is not necessary for phototherapy. The primary goal of phototherapy is to treat jaundice, and providing glucose water is not directly related to this treatment.
Option b)Applying a thin layer of lotion to the newborn's skin every 8 hours is not necessary during phototherapy. In fact, it is generally recommended to avoid applying lotions or oils to the skin during phototherapy as they can interfere with the effectiveness of the treatment.
Option c) Ensuring the newborn's eyes are closed beneath the shield is essential during phototherapy. The eyes are particularly sensitive to the light used in phototherapy, and exposure to the light can potentially damage the eyes. Therefore, the newborn's eyes should be protected with a shield or eye patches to prevent direct exposure to the light.
Option d) Dressing the newborn in a thin layer of clothing during therapy is appropriate. The newborn should be dressed in a way that allows as much of their skin as possible to be exposed to the phototherapy lights. This usually involves removing unnecessary clothing and covering the genital area with a diaper, while the rest of the body is exposed to the light.
Correct Answer is D
Explanation
An indirect Coombs' test, also known as an indirect antiglobulin test, is used to detect antibodies in your bloodstream that could attach to red blood cells¹². It is used as a screening process to see how you'll react to a blood transfusion². An indirect Coombs' test is also routinely given as part of prenatal testing to see if you have antibodies against Rh-positive blood¹. If you have an Rh-negative blood type and your baby has an Rh-positive blood type, then your immune system could make antibodies that attack your baby's red blood cells¹. This can cause a condition called Rh disease, which can lead to anemia, jaundice or other serious health problems for your baby¹. The indirect Coombs' test can help prevent or treat this problem by detecting the presence of Rh-positive antibodies in your blood¹².
The other options are incorrect because they describe different tests or purposes:
a) The amount of amniotic fluid around the fetus is measured by an ultrasound scan, not by a blood test.
b) The risk of hypoglycemia (low blood sugar) after birth is assessed by measuring the baby's blood glucose level, not by a maternal blood test.
c) The blood flow in the fetus and placenta is studied by a Doppler ultrasound scan, not by a blood test.
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