A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
Administer oxygen at 10 L/min via nonrebreather facemask.
Initiate an amnioinfusion.
Instruct the client to bear down and push with contractions.
Place the client in a supine position.
The Correct Answer is A
A.
Rationale:
A. Administering oxygen helps improve oxygenation to the fetus and is the priority intervention for late decelerations.
B. Amnioinfusion may be considered for variable decelerations caused by oligohydramnios but is not indicated for late decelerations.
C. Instructing the client to bear down and push with contractions is not appropriate for addressing late decelerations and may worsen fetal distress.
D. Placing the client in a supine position can exacerbate late decelerations by reducing blood flow to the uterus and should be avoided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
Rationale:
A. Lentils are a legume known for their high fiber content, making them an excellent choice for increasing dietary fiber.
B. While cabbage is a vegetable, it does not contain as much fiber per cup as lentils.
C. Asparagus is a vegetable that contains fiber, but it typically has lower fiber content per cup compared to lentils.
D. Oatmeal is a grain that contains fiber, but lentils generally have a higher fiber content per cup than oatmeal.
Correct Answer is D
Explanation
Rationale:
A. Administering oxygen via a nonrebreather mask may be indicated for fetal distress, but the priority in this situation is to protect the umbilical cord from compression and minimize fetal compromise.
B. Cover the umbilical cord with a sterile saline-saturated towel is an appropriate action to prevent the cord from drying out and to reduce infection butimmediate focus should be on relieving pressure on the umbilical cord to ensure adequate fetal perfusion.
C. Initiate an infusion of IV fluids for the client can help stabilize maternal hemodynamics, but it does not directly address the umbilical cord compression. Relieving the pressure on the cord is the immediate intervention to prevent fetal hypoxia.
D. Perform a vaginal examination by applying upward pressure on the presenting part is the priority intervention. In cases of umbilical cord prolapse, the nurse must perform a vaginal examination and apply upward manual pressure on the presenting part (usually the fetal head) to lift it off the umbilical cord. This action relieves compression on the cord and restores blood flow and oxygen delivery to the fetus until an emergency delivery can be performed.
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