A nurse is performing a nonstress test for a client who is at 38 weeks of gestation. The fetal monitor tracing reveals a series of late decelerations.
Which of the following interventions should the nurse implement first?
Place the client in a lateral position.
Administer lactated Ringer's via IV bolus.
Prepare the client for a cesarean birth.
Elevate the client's legs.
The Correct Answer is A
Choice A rationale
Late decelerations indicate uteroplacental insufficiency, meaning reduced blood flow and oxygen to the fetus. Placing the client in a lateral position (left or right side) can alleviate pressure on the vena cava, improving venous return to the heart, thus increasing cardiac output and uteroplacental perfusion. This is the least invasive initial intervention.
Choice B rationale
While intravenous fluid administration may be indicated in some cases to improve maternal hydration and placental perfusion, repositioning the client is a more immediate and less invasive intervention to address uteroplacental insufficiency by optimizing maternal circulation and oxygen delivery to the fetus.
Choice C rationale
Preparing for a cesarean birth is a significant intervention reserved for persistent or severe fetal distress that does not respond to less invasive measures. Although late decelerations are concerning, immediate surgical intervention is not the first step without attempting to optimize fetal well-being through maternal repositioning.
Choice D rationale
Elevating the client's legs might slightly increase venous return, but it is not the primary intervention for late decelerations. The lateral position is more effective in relieving aortocaval compression, directly addressing the underlying issue of reduced placental blood flow, and is the established first-line intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Dark and concentrated urine in an infant indicates inadequate hydration, which can be a sign of insufficient milk intake during breastfeeding. Well-hydrated infants, receiving adequate breast milk, typically produce urine that is pale yellow and dilute, not dark and concentrated. This reflects proper kidney function and fluid balance.
Choice B rationale
After effective breastfeeding, the breasts should feel softer and less engorged, not firm. The firmness before feeding is due to milk accumulation within the mammary glands. As the infant removes milk, the pressure decreases, leading to a softer breast texture, indicating successful milk transfer.
Choice C rationale
A tugging sensation during breastfeeding is a normal and expected physiological sign. This sensation results from the baby's effective latch and negative pressure creation, which draws milk from the milk ducts into the baby's mouth. It signifies proper milk ejection and efficient feeding.
Choice D rationale
Two to three wet diapers in a 24-hour period for a 5-day-old infant is indicative of insufficient fluid intake. A well-hydrated newborn at this age, receiving adequate breast milk, should typically have six to eight wet diapers per 24 hours, reflecting sufficient hydration and milk transfer.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A,B"}}
Explanation
Abruptio Placentae: Typically does not cause increased contraction frequency; contractions may be normal or decreased due to uterine irritation or pain.
Uterine Tachysystole: Characterized by more than 5 contractions in 10 minutes averaged over 30 minutes, indicating excessive contraction frequency, which can reduce uteroplacental perfusion.
Uterine Tone
Abruptio Placentae: The uterus often becomes firm, rigid, and tender due to bleeding and inflammation caused by premature placental separation, increasing baseline uterine tone.
Uterine Tachysystole: Uterine tone is elevated because contractions are prolonged and close together, causing the uterus to remain tense with insufficient relaxation.
Pain Report
Abruptio Placentae: Patients usually report sharp, severe abdominal or back pain due to the sudden placental detachment and uterine irritation.
Uterine Tachysystole: Pain may be present but is typically related to frequent contractions rather than sharp, localized pain.
FHR Pattern
Abruptio Placentae: Commonly causes fetal heart rate abnormalities like late decelerations, bradycardia, or absent variability due to fetal hypoxia from compromised placental perfusion.
Uterine Tachysystole: Can cause decreased fetal heart rate variability and late decelerations because frequent contractions reduce oxygen delivery during inadequate relaxation.
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