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 D
Explanation
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.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale:
Pointing out to the father that the newborn turns toward his voice helps him understand that the baby is already responding to him, promoting bonding.
Choice B rationale:
Asking the father why he is concerned about bonding with the newborn allows the nurse to address specific fears or misconceptions and provide appropriate support.
Choice C rationale:
Encouraging the father to touch and stroke the newborn's skin promotes physical contact and enhances the bonding process.
Choice D rationale:
Demonstrating diapering and swaddling techniques for the father helps him feel more confident in caring for his baby and fosters bonding through caregiving activities.
Choice E rationale:
Encouraging the father to lay the newborn beside him while both are sleeping promotes skin- to-skin contact and allows for bonding during restful moments. However, the nurse should ensure that safety measures are followed to prevent accidental suffocation. By following these actions, the nurse can support the father's bonding with his newborn and facilitate a positive and nurturing parent-infant relationship.
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