A practical nurse is assigned to assist in the care of a laboring client at 42-weeks gestation with maternal intrapartum fever, chorioamnionitis. Four hours after admission, the practical nurse observes fetal heart rate decelerations occurring after the peak of contractions.
Which action should the practical nurse take?
Perform deep tendon reflexes every 4 hours.
Help the client move to a left side-lying position.
Insert an indwelling urinary catheter to monitor hourly output.
Collect a urine specimen for electrolytes and protein.
The Correct Answer is B
Choice A rationale
Performing deep tendon reflexes every 4 hours is primarily indicated for clients at risk of magnesium sulfate toxicity, not directly for fetal heart rate decelerations after the peak of contractions. These decelerations suggest uteroplacental insufficiency, where oxygen supply to the fetus is compromised, and magnesium sulfate is used for pre-eclampsia.
Choice B rationale
A left side-lying position alleviates compression of the inferior vena cava and aorta by the gravid uterus, thereby improving uteroplacental blood flow and oxygen delivery to the fetus. This physiological change can often resolve late decelerations, which are indicative of uteroplacental insufficiency due to reduced maternal blood flow.
Choice C rationale
Inserting an indwelling urinary catheter to monitor hourly output is essential for assessing fluid balance and renal perfusion, especially in high-risk pregnancies or those receiving intravenous fluids. However, it does not directly address or correct fetal heart rate decelerations caused by uteroplacental insufficiency.
Choice D rationale
Collecting a urine specimen for electrolytes and protein is a diagnostic measure for conditions like pre-eclampsia, which involves proteinuria and electrolyte imbalances. While important for overall maternal assessment, it does not provide an immediate intervention for late fetal heart rate decelerations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A visit summary documenting the report of abuse may be legally required for documentation but does not directly provide the client with immediate safety resources. The priority is to empower the client with actionable steps to ensure her safety and well-being in an abusive situation.
Choice B rationale
Contact information for a women's shelter provides a crucial immediate resource for safety and support. These shelters offer a safe haven, counseling, and assistance with legal and social services, empowering the client to escape the abusive environment and access necessary resources for herself and potentially her children.
Choice C rationale
Paperwork needed to file a restraining order is a legal step that the client may choose to pursue later. However, in an immediate confiding situation, providing a direct safety resource like shelter information is more paramount, as filing a restraining order requires time and legal processes that may not offer immediate protection.
Choice D rationale
A safety plan to keep in a purse at all times is a valuable tool for future use but does not address the immediate need for a safe place or resources. While important for long-term safety, the initial intervention should focus on providing immediate pathways to escape the abusive situation.
Correct Answer is D
Explanation
Choice A rationale
This schedule is incorrect for pertussis (whooping cough) immunization. Pertussis vaccination, usually as part of the DTaP vaccine, is initiated in infancy and requires multiple doses to build adequate immunity, not just a single dose at 1 year or 6 years of age.
Choice B rationale
This schedule is incorrect and deviates from the standard recommendations for pertussis vaccination. The typical primary series of DTaP vaccination begins earlier in infancy and includes specific booster doses at later ages to maintain protection against the disease.
Choice C rationale
This schedule is incorrect for pertussis immunization. While some vaccinations begin at birth, and boosters are given periodically, the specific timing and frequency for pertussis in this option do not align with the established guidelines for the DTaP or Tdap vaccines.
Choice D rationale
This is the recommended immunization schedule for pertussis, typically administered as part of the DTaP vaccine. The primary series at 2, 4, and 6 months establishes foundational immunity, and boosters at 15-18 months and 4-6 years of age are crucial for maintaining long-term protection against the disease.
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