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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The client's statement about needing to have the IUD replaced each year is incorrect. The lifespan of most IUDs is longer than a year. Copper IUDs can last up to 10 years, and hormonal IUDs can last between 3 to 7 years, depending on the brand.
Choice B rationale:
The client's statement about needing to apply a spermicide prior to intercourse is unrelated to the correct use of an intrauterine device (IUD) for contraception. Spermicides are not required when using an IUD.
Choice C rationale:
The client's statement about expecting periods to stop while having the IUD is incorrect. Hormonal IUDs can often lead to lighter periods, and in some cases, periods may stop altogether. However, with a copper IUD, periods usually remain the same.
Choice D rationale:
This is the correct choice. The client's statement indicates an understanding of the teaching. Checking for the string each month after menstruation is crucial because it confirms that the IUD is still in place, reducing the risk of unintended pregnancy.
Correct Answer is A
Explanation
Choice A rationale:
Rh incompatibility occurs when an Rh-negative client is exposed to Rh-positive fetal blood, typically during a prior pregnancy or delivery. The client’s immune system produces anti-Rh antibodies that cross the placenta in subsequent pregnancies, attacking the Rh-positive red blood cells of the fetus. This hemolysis releases bilirubin, leading to hyperbilirubinemia in the newborn.
Choice B rationale:
Rh incompatibility only occurs when the client is Rh-negative and the fetus is Rh-positive. An Rh-positive client will not form antibodies against an Rh-negative fetus, as their immune system recognizes the Rh factor as normal.
Choice C rationale:
This choice is not related to the mechanism of Rh incompatibility. Receiving a transfusion with Rh-negative blood would not cause the mother's immune system to produce anti-Rh antibodies or lead to Rh incompatibility with her newborn.
Choice D rationale:
This choice describes the ABO blood group system, not the Rh factor. ABO incompatibility can occur when a mother with blood type O (producing anti-A and anti-B antibodies) has a newborn with blood type A, B, or AB, leading to hemolysis of the fetal red blood cells. However, the question specifically mentions Rh incompatibility, which involves the Rh factor, not the ABO system.
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