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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Tremors are a common side effect of terbutaline. Terbutaline is a medication used to inhibit uterine contractions in preterm labor. It is a beta-adrenergic agonist, and stimulation of the beta-adrenergic receptors can lead to side effects such as tremors.
Correct Answer is B
Explanation
Choice A rationale
Frothy pink drainage is not typically associated with an upper gastrointestinal bleed. This type of drainage might be seen in other conditions, such as pulmonary edema where the fluid from the lungs can sometimes appear frothy and pink.
Choice B rationale
Coffee-ground drainage is a common finding in patients with an active upper gastrointestinal bleed. When blood mixes with gastric acid, it can create a substance that resembles coffee grounds. This is often seen when a nasogastric (NG) tube is inserted into the patient.
Choice C rationale
Dark amber drainage is not typically associated with an upper gastrointestinal bleed. This type of drainage might be seen in other conditions, such as liver disease where the urine can sometimes appear dark amber.
Choice D rationale
Greenish-yellow drainage is not typically associated with an upper gastrointestinal bleed. This type of drainage might be seen in other conditions, such as bile duct obstruction where the bile can sometimes appear greenish-yellow.
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