A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?

Change the client's position.

Insert a scalp electrode.

Prepare for amnioinfusion.

Document benign decelerations.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The priority nursing action when the fetal heart rate shows a deceleration after the contraction has started, with the lowest point occurring after the peak of the contraction, is to change the client's position. This deceleration pattern is called "late decelerations,” and it is typically associated with uteroplacental insufficiency, which can be caused by maternal hypotension or impaired blood flow to the placenta. Changing the client's position, such as moving the client to their side or repositioning them, can alleviate pressure on the vena cava and improve blood flow to the placenta, thus potentially resolving or minimizing the late decelerations.

Choice B rationale:

Inserting a scalp electrode (Choice B) is not the priority action in this situation. While a scalp electrode may be used to monitor the fetal heart rate more accurately and continuously, it is not the initial intervention for addressing late decelerations.

Choice C rationale:

Preparing for amnioinfusion (Choice C) may be considered if there are variable decelerations (caused by cord compression) present, but it is not the priority intervention for late decelerations.

Choice D rationale:

Documenting benign decelerations (Choice D) is not appropriate in this scenario since late decelerations are not considered benign and require immediate action.

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Correct Answer is D

Explanation

Choice A rationale:

Increased pancreatic activity during pregnancy causing fat intolerance is not related to the cause of indigestion and heartburn. Pancreatic activity can change during pregnancy, but it does not directly impact indigestion and heartburn.

Choice B rationale:

Increased estrogen production causing more hydrochloric acid in the stomach is not the cause of indigestion and heartburn during pregnancy. While hormones can influence digestion, the mechanism for indigestion and heartburn lies elsewhere.

Choice C rationale:

Pressure from the growing uterus pushing up on the stomach and intestines is a contributing factor to indigestion and heartburn during pregnancy. However, it is not the primary cause. The main cause is related to the relaxation of the cardiac sphincter.

Choice D rationale:

Progesterone causes relaxation of the cardiac sphincter, which is a muscular valve that prevents stomach acid from flowing back into the esophagus. When this sphincter relaxes, it can lead to acid reflux and subsequent indigestion and heartburn during pregnancy. The nurse should educate the client about this hormonal effect to help manage these symptoms effectively.

A. Fentanyl. B. Flumazenil. C. Naloxone. D. Benztropine.

Correct Answer is C

Explanation

Choice A rationale:

Fentanyl is an opioid analgesic and is not used to counteract the effects of meperidine in the newborn. Both fentanyl and meperidine are opioids, and using fentanyl in this context would not counteract the effects of meperidine.

Choice B rationale:

Flumazenil is a medication used to reverse the effects of benzodiazepines, not opioids like meperidine. It is not appropriate for countering the effects of meperidine in the newborn.

Choice C rationale:

Naloxone is an opioid antagonist that can reverse the effects of opioids like meperidine. When a newborn has been exposed to opioids during labor, such as meperidine given to the mother, there is a risk of respiratory depression in the newborn. Naloxone can quickly reverse this effect and restore normal respiratory function.

Choice D rationale:

Benztropine is an anticholinergic medication used to treat side effects of antipsychotic drugs and is not relevant in this situation. It would not counteract the effects of meperidine on the newborn.

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A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?

Correct Answer is D

Explanation

A laboring client received meperidine IV one hour prior to delivery. Which of the following medications should the nurse have available to counteract the effects of this medication on the newborn?

Correct Answer is C

Explanation

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