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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Sternal retractions indicate increased respiratory effort and can be a sign of respiratory distress in a newborn. This occurs when the infant is struggling to inhale, causing the chest wall to visibly pull inward with each breath due to negative pressure, and requires immediate intervention.

Choice B rationale

Acrocyanosis, characterized by bluish discoloration of the hands and feet, is a common and normal finding in newborns during the first 24 to 48 hours after birth. It is due to immature peripheral circulation and does not typically indicate a need for intervention.

Choice C rationale

Molding is the overlapping of the fetal skull bones during passage through the birth canal. This is a normal adaptation during vaginal birth and typically resolves spontaneously within a few days, thus requiring no intervention.

Choice D rationale

Vernix caseosa is a whitish, cheesy substance covering the skin of many newborns, providing protection and lubrication in utero. Its presence is normal and beneficial, often providing hydration and antimicrobial properties to the skin post-birth.

A. Leave the ring inserted for 3 weeks followed by a week without the ring. B. Contact your provider for a new ring if you gain or lose more than 4.5 kg (10 lb). C. Wash the ring with warm soap and water after each use. D. Insert the ring up to 6 hours before sexual intercourse.

Correct Answer is A

Explanation

Choice A rationale

The vaginal contraceptive ring is designed for cyclic use, specifically to be left inserted for 3 consecutive weeks, followed by a 1-week ring-free interval. This regimen allows for a withdrawal bleed during the ring-free week, mimicking a natural menstrual cycle while maintaining contraceptive efficacy by providing continuous hormone release for 21 days.

Choice B rationale

Body weight fluctuations of 4.5 kg (10 lb) do not significantly impact the effectiveness of the vaginal contraceptive ring. The ring delivers a localized and consistent dose of hormones that is not dependent on systemic absorption influenced by minor weight changes. Therefore, contacting a provider for a new ring due to this weight change is unnecessary.

Choice C rationale

The vaginal contraceptive ring should not be washed with soap and water after each use. The ring is a single-use, disposable device designed to be inserted and remain in place for the full 3-week duration. Washing it could potentially degrade the material or interfere with the controlled release of hormones, compromising its efficacy.

Choice D rationale

The vaginal contraceptive ring does not need to be inserted immediately before sexual intercourse. It provides continuous contraceptive protection as long as it is inserted and used correctly according to the 3-week in, 1-week out schedule. Its efficacy is not tied to the timing of individual sexual acts.

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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?

Nursing Test Bank

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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?