If the fetal monitor demonstrates a specific pattern, which action would the nurse perform first?
Prepare for vaginal delivery.
Administer oxygen at 3 liters via nasal cannula.
Turn the client or ask the client to turn on their side.
Perform a vaginal exam to assess for the umbilical cord.
The Correct Answer is C
Choice A rationale
Preparing for a vaginal delivery is not the first action to perform based on a specific fetal monitor pattern. The initial step is to identify the cause of the non-reassuring pattern and attempt to correct it with less invasive measures. Preparing for delivery is a more advanced intervention and is considered only after other interventions, such as changing maternal position, administering oxygen, and providing intravenous fluids, have failed to resolve the fetal distress pattern.
Choice B rationale
Administering oxygen at 3 liters via nasal cannula is a supportive measure to increase fetal oxygenation. However, it is not the first action. The most immediate and effective first step is to improve uterine blood flow and placental perfusion by changing the maternal position. Decreasing pressure on the vena cava and aorta is a more direct way to improve oxygen delivery to the fetus than administering oxygen to the mother.
Choice C rationale
Turning the client or asking them to turn on their side is the first action. This maneuver relieves pressure on the maternal vena cava and aorta, which can be caused by the gravid uterus. By improving venous return and cardiac output, this position change directly increases blood flow to the placenta. This enhanced placental perfusion often corrects non-reassuring fetal heart rate patterns, such as late decelerations, by improving oxygen delivery to the fetus.
Choice D rationale
Performing a vaginal exam to assess for the umbilical cord is an important assessment, but it is not the first action. While a vaginal exam is necessary to rule out a prolapsed cord, especially with sudden changes in the fetal heart rate, it should be done after attempting the less invasive and immediate intervention of changing the client's position. Position change is a quick and non-invasive way to improve fetal oxygenation and is the priority initial step.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A localized area of breast tenderness is a potential sign of mastitis, which, while requiring attention, is not an immediate life-threatening condition. The client can be seen after more acute priorities, as mastitis typically develops over days.
Choice B rationale
A pain score of 3/10 in a 4-hour post-op client is an expected finding and can be addressed after more critical clients. This level of pain is not indicative of an acute, unstable physiological state that requires immediate intervention.
Choice C rationale
Moderate, dark red lochia is a normal finding 4 hours postpartum. The lochia is a mixture of blood, tissue, and mucus, and its color and amount are expected to change over time without indicating an immediate danger to the client.
Choice D rationale
Uterine tenderness, foul-smelling lochia, and a new temperature of 102 degrees F are classic signs of postpartum endometritis, a serious uterine infection. This presents a high risk for sepsis and septic shock, making it the highest priority for immediate assessment and intervention. .
Correct Answer is D
Explanation
Choice A rationale
Increasing nasal discharge is a common symptom of upper respiratory tract infections and does not specifically indicate a progression to airway occlusion in croup. While it contributes to overall respiratory distress, it is not the most critical sign of a life-threatening compromise of the airway in this condition.
Choice B rationale
A harsher cough, often described as a "barking" cough, is a characteristic symptom of croup caused by inflammation of the larynx, trachea, and bronchi. While concerning, it is not the most reliable indicator of impending airway occlusion. The cough may be present throughout the illness without a complete occlusion.
Choice C rationale
An increasing respiratory rate is an early compensatory mechanism in response to airway obstruction and hypoxia. While it indicates respiratory distress, it is not the most significant sign of impending airway occlusion. It can occur with many respiratory issues and is often a precursor to more severe signs.
Choice D rationale
A toddler stating they are tired and wanting to sleep is a serious and late sign of hypoxia. This indicates that the child is becoming fatigued from the increased work of breathing, leading to decreased respiratory effort. This mental status change signals that the body's compensatory mechanisms are failing, and respiratory failure and airway occlusion are imminent.
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