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 []
Explanation
Potential Condition:
- B. Type 1 diabetes mellitus
The client’s symptoms of fatigue, blurred vision, dizziness, and headache, along with a high blood glucose level and HbA1C, suggest that they are experiencing hyperglycemia, a condition common in individuals with Type 1 diabetes mellitus.
Actions to Take:
- B. Teach the client about the signs of hyperglycemia.
- D. Assess the client’s feet for sensation.
Teaching the client about the signs of hyperglycemia will help them recognize when their blood sugar is high and take appropriate action. Assessing the client’s feet for sensation is also important as diabetes can lead to peripheral neuropathy, which can result in a loss of sensation in the feet.
Parameters to Monitor:
- B. Blood pressure
- D. Fingerstick blood glucose
Monitoring the client’s blood pressure is important as hypertension can be a complication of diabetes. Regularly checking the client’s fingerstick blood glucose levels will help ensure that their diabetes is being effectively managed.
Correct Answer is A
Explanation
Choice A rationale
The rubella vaccine is a live vaccine, which means it contains a weakened version of the virus. Because the virus is still active, live vaccines are not safe for pregnant people. There is a small chance they may pass the virus to the baby. Therefore, it is recommended that adults of childbearing age should avoid getting pregnant for at least four weeks after receiving the MMR vaccine. This is to ensure the safety of both the mother and the baby.
Choice B rationale
This statement is incorrect. The rubella vaccine does not require additional shots after each baby with Rh-positive blood. The rubella vaccine is typically administered in childhood and provides long-term protection.
Choice C rationale
This statement is also incorrect. The rubella vaccine does not require additional shots in 1 month and again in 6 months. The vaccine provides long-term protection and does not typically require frequent boosters.
Choice D rationale
While it’s true that some vaccines can cause side effects such as fever and vomiting, these are not common side effects of the rubella vaccine. Therefore, this statement is not entirely accurate.
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