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.

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Correct Answer is A

Explanation

Choice A rationale

At about 12 hours after delivery, the uterine fundus can be palpated at 1 cm above the umbilicus. This is the correct answer.

Choice B rationale

One fingerbreadth above the symphysis pubis is not where the uterine fundus is expected to be found 12 hours after a vaginal delivery.

Choice C rationale

At the level of the umbilicus is not where the uterine fundus is expected to be found 12 hours after a vaginal delivery.

Choice D rationale

To the right of the umbilicus is not where the uterine fundus is expected to be found 12 hours after a vaginal delivery.

A. A client diagnosed with preeclampsia reports epigastric pain and unresolved headache B. A tearful client at 32 weeks of gestation experiencing irregular, frequent contractions C. A client diagnosed with preeclampsia has 2+ proteinuria and 2+ patellar reflexes D. A client at 28 weeks of gestation receiving terbutaline reports fine tremors

Correct Answer is A

Explanation

Choice A rationale

A client diagnosed with preeclampsia reporting epigastric pain and unresolved headache is a serious concern. Epigastric pain could indicate severe liver involvement, and a persistent headache could be a sign of progressing neurological involvement, both of which are severe features of preeclampsia. These symptoms suggest the condition may be worsening to eclampsia, a life-threatening complication characterized by the onset of seizure activity or coma in a woman with preeclampsia. Immediate medical attention is necessary to prevent further complications.

Choice B rationale

A tearful client at 32 weeks of gestation experiencing irregular, frequent contractions could be experiencing preterm labor. However, emotional distress and contractions do not necessarily indicate a medical emergency. It’s important to monitor the situation, but it does not need to be immediately reported to the provider.

Choice C rationale

A client diagnosed with preeclampsia having 2+ proteinuria and 2+ patellar reflexes are expected findings. Proteinuria is a common sign of preeclampsia, and hyperreflexia can occur due to increased neuromuscular irritability. While these should be monitored, they do not need to be immediately reported to the provider.

Choice D rationale

A client at 28 weeks of gestation receiving terbutaline reporting fine tremors is an expected side effect of the medication. Terbutaline, a beta-adrenergic agonist, can cause tremors by stimulating the nervous system. While it may be uncomfortable for the client, it is not a medical emergency.

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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 is caring for a patient who had a vaginal delivery 12 hours ago.Where should the nurse expect to find the uterine fundus when palpating the patient’s abdomen?

Correct Answer is A

Explanation

As a nurse caring for a group of clients on an intrapartum unit, which of the following findings should be immediately reported to the provider?

Correct Answer is A

Explanation

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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?