A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
Prepare the equipment necessary to initiate an amnioinfusion.
Administer oxygen at 10 L/min via a nonrebreather face mask.
Discontinue the infusion of oxytocin.
Place the client in a left lateral position.
The Correct Answer is D
Choice A reason:
Preparing for an amnioinfusion is not the first-line action. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.
Choice B reason:
Administering oxygen is a subsequent measure if initial interventions like repositioning do not improve the FHR. Oxygen is typically given at 8-10 L/min via a nonrebreather mask to increase fetal oxygenation.
Choice C reason:
Discontinuing oxytocin is important if the cause of decelerations is uterine hyperstimulation. However, repositioning the client should precede this action to quickly address potential umbilical cord compression.
Choice D reason:
This is the first action to take because it can quickly alleviate potential compression of the umbilical cord, which is often the cause of variable decelerations. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Initiate continuous monitoring of the FHR. For a client with placenta previa, continuous fetal heart rate (FHR) monitoring is essential to assess the baby's well-being due to the risk of fetal distress from reduced oxygen supply
Choice A reason:
Continuous FHR monitoring is a standard care practice for clients with placenta previa to promptly detect any signs of fetal distress and intervene as necessary.
Choice B reason:
Betamethasone is typically administered to enhance fetal lung maturity before 34 weeks of gestation, not for placenta previa. Its use at 35 weeks is less common unless there's a risk of preterm birth within 7 days and the patient hasn't received a previous course.
Choice C reason:
Checking the cervix can induce bleeding and is contraindicated in placenta previa because it may disturb the placental site and exacerbate bleeding.
Choice D reason:
Misoprostol is used for labor induction or to treat postpartum hemorrhage. It is not indicated for placenta previa management and can cause uterine contractions leading to increased bleeding.
Correct Answer is ["C","D","E"]
Explanation
The correct answers are C, D, E.
Choice A reason:
Performing a vaginal exam is contraindicated in placenta previa because it can disrupt the placenta and cause significant bleeding.
Choice B reason:
Monitoring fetal heart rate with an internal fetal monitor is not recommended as it involves a vaginal exam, which poses a risk of bleeding in placenta previa cases.
Choice C reason:
Frequently assessing maternal heart rate is important to detect any changes that could indicate maternal hemorrhage or other complications.
Choice D reason:
Initiating bed rest with bathroom privileges is advised to minimize the risk of bleeding and to ensure the safety of both the mother and the fetus.
Choice E reason:
Having oxygen equipment available is essential to manage potential fetal distress, which can occur with placenta previa.
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