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.

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Correct Answer is C

Explanation

Answer and explanation..

The correct answer is choice C. Jitteriness.Jitteriness is a sign of low blood sugar (hypoglycemia) which is common in infants of diabetic mothers (IDM) because they have high levels of insulin in their blood that lower their glucose levels after birth.Hypoglycemia can also cause other symptoms such as seizures, lethargy, poor feeding, sweating, trembling, and pale complexion.

Choice A is wrong because abdominal distention is not a typical symptom of IDM.

It can be caused by other conditions such as intestinal obstruction or infection.

Choice B is wrong because high-pitched cry is not a specific symptom of IDM.

It can be caused by many factors such as pain, hunger, or neurological problems.

Choice D is wrong because excessive drooling is not a common symptom of IDM.

It can be a sign of oral problems such as teething or infection.

Normal ranges for blood glucose in newborns are 40 to 150 mg/dL (2.2 to 8.3 mmol/L).

IDM should be monitored closely for hypoglycemia and treated promptly with glucose if needed.

A. The amount of sexual experience that the patient has had. B. The type of contraceptive that the patient’s friends are using. C. The reason for the patient’s visit at this time. D. The method of contraception that the patient believes will provide protection from sexually transmitted diseases.

Correct Answer is C

Explanation

The correct answer is choice C. The reason for the patient’s visit at this time.

This information will help the nurse assess the patient’s motivation, readiness, and urgency for contraception.

It will also help the nurse tailor the education and counseling to the patient’s specific needs and preferences.

Choice A is wrong because the amount of sexual experience that the patient has had is not relevant to determine the patient’s knowledge base.

It may also make the patient feel uncomfortable or judged.

Choice B is wrong because the type of contraceptive that the patient’s friends are using is not a reliable source of information.

Different methods may have different advantages and disadvantages for different people.

The nurse should provide evidence-based information and guidance on various options.

Choice D is wrong because the method of contraception that the patient believes will provide protection from sexually transmitted diseases may not be accurate or effective.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn of a diabetic mother (IDM). What should the nurse monitor for during care of the newborn?

Correct Answer is C

Explanation

A patient comes to the family planning clinic requesting information.Which information should the nurse obtain initially to determine the patient’s knowledge base?.

Correct Answer is C

Explanation

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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?