A nurse is providing care for a patient who is in active labor and recognizes late decelerations on the fetal monitor.
The healthcare provider has been informed.
What is the nurse’s priority action?

Administer oxygen via face mask.

Elevate the patient’s legs.

Have the patient turn to a side-lying position.

Increase the infusion rate of the IV fluid.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Administering oxygen via face mask is a common intervention for many complications during labor. However, it is not the first-line intervention for late decelerations. Late decelerations are a sign of fetal distress, often due to uteroplacental insufficiency. While oxygen can help increase oxygenation to the fetus, it does not address the root cause of the problem.

Choice B rationale

Elevating the patient’s legs is not typically the priority action when late decelerations are noted. This action would not alleviate the cause of late decelerations.

Choice C rationale

Having the patient turn to a side-lying position is often the first intervention when late decelerations are noted. This position helps increase blood flow to the placenta, potentially alleviating uteroplacental insufficiency and improving fetal oxygenation.

Choice D rationale

Increasing the infusion rate of IV fluids is not the first-line intervention for late decelerations. While it may be part of the management plan, it is not the priority action.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice B rationale

Hypertension is the most common risk factor for placental abruption. Hypertension can cause constriction of the blood vessels, including those in the placenta, which can lead to detachment of the placenta from the uterine wall.

A. “We can wait until your next appointment to check you.”. B. “As long as the baby is still moving around, there is nothing to worry about.”. C. “Go to the hospital right away.”. D. “Call back in 2 hours and tell me if there is any change in the leakage.”.

Correct Answer is C

Explanation

Choice A rationale

Waiting until the next appointment could potentially put both the mother and the baby at risk. Leakage of vaginal fluid could indicate premature rupture of membranes, which can lead to infection or premature labor.

Choice B rationale

While fetal movement is a good sign, it does not rule out potential complications associated with leakage of vaginal fluid. Therefore, this advice could lead to a delay in necessary medical intervention.

Choice C rationale

This is the most appropriate response. Leakage of vaginal fluid in a pregnant woman could be a sign of premature rupture of membranes, which can lead to complications such as infection or premature labor. Immediate medical attention is necessary to assess the situation and take appropriate action.

Choice D rationale

Asking the client to wait and see if the leakage changes could potentially delay necessary medical intervention. It’s important to seek immediate medical attention to assess the situation and take appropriate action.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is providing care for a patient who is in active labor and recognizes late decelerations on the fetal monitor.The healthcare provider has been informed.What is the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption.The nurse should recognize that which of the following is the most common risk factor for abruption?

Correct Answer is B

Explanation

A 23 weeks pregnant client calls the clinic and reports leakage of vaginal fluid.What should be the appropriate response by the nurse?

Correct Answer is C

Explanation

A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition.Which of the following instructions should be included?

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn.The client reports feeling “down” and sad, having no energy, and wanting to cry.What should be the nurse’s priority action?

In the context of caring for a patient diagnosed with Crohn’s disease, which nursing assessment should be prioritized?

Exhibits Based on the information in the newborn's medical record, the nurse determines that the newborn is at risk for developing which of the following complications?

A nurse is reviewing the medical record of a client who has moderate Alzheimer's disease. Exhibits To effectively manage the provider prescriptions, which of the following tasks should the nurse assign to an assistive personnel (AP)?

A nurse is caring for four clients who have various types of drainage tubes.Which of the following clients should the nurse identify as being at risk for hypokalemia?

A nurse is educating a patient diagnosed with cholelithiasis about the upcoming oral cholangiogram.Which statement by the patient indicates that the education was effective?

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor.The client has a new prescription for magnesium sulfate.Which of the following explanations should the nurse provide about the purpose of this medication?

A nurse is providing care for a patient who is in active labor and recognizes late decelerations on the fetal monitor.
The healthcare provider has been informed.
What is the nurse’s priority action?