A nurse is collecting data from a fetal monitor strip and recognizes late decelerations.
Which of the following actions should the nurse expect to be taken at this time?

Reposition the client to a left lateral position.

Document the findings in the electronic health record.

Adjust the fetal monitor sensors.

Insert a fetal scalp electrode.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Repositioning the client to a left lateral position aims to improve uteroplacental perfusion by alleviating compression of the inferior vena cava by the gravid uterus. This enhances venous return to the mother's heart, increasing cardiac output and ultimately improving blood flow and oxygen delivery to the placenta and fetus, which can resolve late decelerations caused by uteroplacental insufficiency.

Choice B rationale

Documenting findings is a crucial nursing responsibility, but it is not the immediate intervention for addressing late decelerations. Scientific principles dictate that physiological stabilization takes precedence over documentation when fetal well-being is compromised. Documentation would follow after initial interventions are implemented to improve the fetal status.

Choice C rationale

Adjusting fetal monitor sensors might be necessary if the tracing is poor quality, but it does not directly address the physiological cause of late decelerations. Late decelerations reflect uteroplacental insufficiency, not merely a monitoring artifact. Addressing the underlying physiological compromise is the priority before troubleshooting equipment.

Choice D rationale

Inserting a fetal scalp electrode provides a more accurate assessment of fetal heart rate by directly monitoring the fetus. However, this is an invasive procedure and is typically considered after initial conservative measures, such as maternal repositioning and oxygen administration, have been attempted without resolution of the late decelerations.

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Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale

Continuous labor support, often provided by doulas or trained birth companions, significantly reduces perceived pain intensity. This is mediated by physiological mechanisms like decreased sympathetic nervous system activation, leading to lower circulating catecholamines, and increased release of endogenous opioids, which naturally mitigate pain signals by binding to mu-opioid receptors in the central nervous system.

Choice B rationale

The presence of a supportive individual during labor fosters a sense of security and control for the birthing person. This psychosocial benefit contributes to a more positive subjective experience, reducing feelings of isolation and fear. Emotional support can lead to increased coping efficacy and a greater sense of satisfaction with the birthing process.

Choice C rationale

Research indicates that continuous labor support is associated with better fetal outcomes, including a reduced incidence of fetal distress and fewer low Apgar scores. This may be attributed to decreased maternal stress hormone levels, which can negatively impact uterine blood flow and oxygen delivery to the fetus, thus promoting a more stable intrauterine environment.

Choice D rationale

Improved client outcomes encompass a range of positive effects, such as reduced rates of medical interventions like epidural anesthesia and cesarean sections. The presence of support often empowers the client to labor more effectively, leading to shorter labor durations and a decreased need for pharmacological pain management, contributing to overall maternal well-being.

Choice E rationale

Increased anxiety is an incorrect benefit. Scientific evidence consistently demonstrates that continuous support during labor actually reduces maternal anxiety and stress levels. The presence of a supportive individual provides emotional reassurance and practical assistance, which helps to alleviate fear and promote a sense of calm during the birthing process.

A. "This medication is administered to prevent neonatal ophthalmia.”. B. "Only newborns born to clients with STIs should receive this medication.”. C. "I will clean the newborn's eyes from inner to outer canthus before administration.”. D. "I will wait at least one minute after administration before wiping the excess.”.

Correct Answer is ["A","C","D"]

Explanation

Choice A rationale

This statement is correct. Erythromycin 0.5% ophthalmic ointment is routinely administered to newborns to prevent ophthalmia neonatorum, which is an infection of the newborn's eyes caused by bacteria such as *Neisseria gonorrhoeae* or *Chlamydia trachomatis* acquired during passage through the birth canal.

Choice B rationale

This statement is incorrect. While the medication prevents neonatal ophthalmia caused by sexually transmitted infections (STIs), it is routinely administered to *all* newborns regardless of the mother's STI status. This is due to the potential for asymptomatic maternal infection and to ensure broad-spectrum prophylaxis.

Choice C rationale

This statement is correct. Cleaning the newborn's eyes from inner to outer canthus before administration removes any discharge or meconium that could interfere with medication absorption or introduce further contamination, ensuring optimal efficacy and preventing the spread of potential pathogens during application.

Choice D rationale

This statement is correct. Waiting at least one minute after administration before wiping the excess allows the medication sufficient time to spread across the conjunctival sac and be absorbed by the ocular tissues, maximizing its prophylactic effect against potential bacterial pathogens present on the eye surface.

Choice E rationale

This statement is incorrect. While the medication does treat conjunctivitis, its primary purpose in newborns is prophylactic, meaning it is given to *prevent* neonatal ophthalmia, not to treat existing conjunctivitis. It is administered to all newborns as a preventative measure against specific bacterial infections.

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A nurse is collecting data from a fetal monitor strip and recognizes late decelerations. Which of the following actions should the nurse expect to be taken at this time?

Nursing Test Bank

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Explanation

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A nurse is collecting data from a fetal monitor strip and recognizes late decelerations.
Which of the following actions should the nurse expect to be taken at this time?