A patient’s labor is induced using an intravenous infusion of 1,000 mL Ringer’s lactate with 10 units of oxytocin.
Two hours later, the nurse notes a pattern of late fetal heart rate decelerations detected on the fetal monitor.Which action is essential for the nurse to take first?

Document the findings.

Pause the oxytocin infusion.

Raise the head of the patient’s bed 30 degrees.

Notify the health care provider.

Answer and Explanation

The Correct Answer is B

This is because late fetal heart rate decelerations are a sign of uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen and nutrients to the fetus. Oxytocin can cause uterine tachysystole, which is excessive and frequent contractions that reduce blood flow to the placenta.Therefore, stopping the oxytocin infusion can help improve placental perfusion and fetal oxygenation.

Choice A is wrong because documenting the findings is not a priority action in this situation.

The nurse should first intervene to address the cause of late decelerations and then document the actions and outcomes.

Choice C is wrong because raising the head of the patient’s bed 30 degrees does not directly affect the placental blood flow or fetal oxygenation.

It may help with maternal comfort and breathing, but it is not an essential action for late decelerations.

Choice D is wrong because notifying the health care provider is not the first action to take.The nurse should first attempt to correct the cause of late decelerations by pausing the oxytocin infusion and then notify the health care provider if there is no improvement or if there are other signs of fetal distress.

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 A

Explanation

he correct answer is choice A. “Instead of having eggs, I am eating yogurt for breakfast.” This statement shows a need for further instruction because eggs are a good source of protein and yogurt is not.

Yogurt is a dairy product that contains mostly carbohydrates and some fat.

Eggs are an animal product that contains mostly protein and some fat.

Protein is important for building and repairing tissues in the body.

Choice B is correct because adding powdered milk to skim milk increases the protein content of the drink.

Powdered milk is a dairy product that contains protein, carbohydrates and fat.

Skim milk is a dairy product that contains protein and carbohydrates but no fat.

Choice C is correct because peanut butter is a good source of protein and healthy fats.

Peanut butter is a plant product that contains protein, fat and some carbohydrates.

Crackers are a grain product that contains mostly carbohydrates and some protein.

Choice D is correct because cream of tomato soup is a good source of protein and calories.

Cream of tomato soup is a processed food that contains tomatoes, cream, flour and seasonings.

Tomatoes are a vegetable that contains mostly water and some carbohydrates.

Cream is a dairy product that contains mostly fat and some protein.

Flour is a grain product that contains mostly carbohydrates and some protein.

Seasonings are herbs and spices that contain mostly flavor and some nutrients.

The normal range of protein intake for adults is 0.8 to 1 gram per kilogram of body weight per day.

This means that an adult who weighs 70 kilograms should consume about 56 to 70 grams of protein per day.

A. Offer her the opportunity for counseling to help her grieve. B. Encourage the woman to hold the deceased twin as well as the living twin. C. Remind her that she should be happy that one child survived and is healthy. D. Assist the woman to take pictures of both babies.

Correct Answer is C

Explanation

The correct answer is choice C. Reminding her that she should be happy that one child survived and is healthy is the least helpful nursing action in supporting the woman as she copes with her loss.

This statement minimizes her grief and implies that she should not feel sad about the deceased twin.

It also disregards her attachment to both babies and her need to mourn the loss of one of them.

Choice A is wrong because offering her the opportunity for counseling to help her grieve is a helpful nursing action that recognizes her emotional distress and provides her with professional support.

Choice B is wrong because encouraging the woman to hold the deceased twin as well as the living twin is a helpful nursing action that allows her to acknowledge and bond with both babies and to create memories that may facilitate healing.

Choice D is wrong because assisting the woman to take pictures of both babies is a helpful nursing action that provides her with tangible mementos of her twins and honors their

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 patient’s labor is induced using an intravenous infusion of 1,000 mL Ringer’s lactate with 10 units of oxytocin. Two hours later, the nurse notes a pattern of late fetal heart rate decelerations detected on the fetal monitor.Which action is essential for the nurse to take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has been instructed to increase the protein in her diet. Which statement by the patient shows a need for further instruction?

Correct Answer is A

Explanation

A woman gives birth to twin girls, one of whom is stillborn. Which nursing action would be least helpful in supporting the woman as she copes with her loss?

Correct Answer is C

Explanation

A patient comes to the antepartal clinic for her visit and provides the nurse with information. What piece of information places this patient at high risk for exposure to teratogenic agents?

During a regular clinic visit, a patient who is 28 weeks pregnant reports leg cramps. The nurse teaches the patient measures to relieve the cramps. Which statement would indicate that the patient understands the teaching?

A patient with no prenatal care is admitted to the labor and delivery unit.She is placed on an external fetal monitor, and an intravenous infusion is begun. A tentative diagnosis of abruptio placentae is made.Which finding would support this diagnosis?

A baby boy is circumcised on the day of discharge. Which observation should the nurse make prior to the infant’s discharge?.

A 23-year-old primigravida who appears to be in her third trimester of pregnancy comes to the labor and delivery unit reporting acute abdominal pain. She has had no prenatal care. Which assessment should the nurse do first?

Which measure should be the nurse’s priority when caring for a set of twins delivered by cesarean delivery?

A patient has decided to bottle-feed her twins.The nurse should give this patient which instruction to help alleviate breast engorgement?

A client in preterm labor tells the nurse, “It’s okay that I am in labor.I’m not worried. My sister’s baby was born this early, and he is doing great.” How should the nurse interpret this statement by the client? The client is:.

A patient’s labor is induced using an intravenous infusion of 1,000 mL Ringer’s lactate with 10 units of oxytocin.
Two hours later, the nurse notes a pattern of late fetal heart rate decelerations detected on the fetal monitor.Which action is essential for the nurse to take first?