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 ["B","C","D","E"]
Explanation
Choice A rationale
Documenting a family history of allergies is important for a complete health history, but it is not a direct documentation of the patient's own reported allergies. The question asks what information to document regarding a patient's reported allergies, so the focus is on the patient's personal experience, not that of their family.
Choice B rationale
The type of allergic reaction is crucial information to document. This helps in distinguishing between a true anaphylactic reaction and a side effect or intolerance. Documenting the specific signs and symptoms, such as rash, hives, or shortness of breath, provides vital information for preventing future exposures and guiding appropriate treatment if one occurs.
Choice C rationale
The medication names are essential to document to prevent future exposure to the same drug. This ensures that the patient does not receive the offending medication again, which is a primary safety measure. It is a fundamental component of a complete allergy record to specify the substance that caused the reaction.
Choice D rationale
Documentation of Epi Pen use is critical as it indicates a severe, anaphylactic reaction requiring an emergency intervention. This information alerts providers to the high risk of a life-threatening allergic response and the need for preparedness, such as having epinephrine available for future exposure.
Choice E rationale
The date of the allergic reaction should be documented to provide a chronological history. This helps in understanding the timeline of the allergy and can be useful for determining if an allergy has changed over time or for correlating the reaction with a specific exposure
Correct Answer is C
Explanation
Choice A rationale
Adjusting the intravenous fluid infusion rate is not the immediate priority after an amniotomy. The primary concern is the potential for umbilical cord prolapse due to the gush of amniotic fluid, which can compromise fetal oxygenation. The fluid rate can be addressed after ensuring fetal well-being.
Choice B rationale
Providing a clean gown and linens is important for client comfort and hygiene but is not a priority over assessing fetal status. A change in linens can be done after the immediate safety of the fetus is confirmed, as a compromised fetal heart rate requires immediate intervention.
Choice C rationale
Assessing the fetal heart rate is the highest priority action after an amniotomy. The sudden release of amniotic fluid increases the risk of an umbilical cord prolapse, where the cord can be compressed, leading to a sudden decrease in fetal oxygenation and an emergent bradycardia. The normal fetal heart rate is 110-160 beats per minute.
Choice D rationale
Assisting the client with perineal hygiene is an important comfort measure and infection prevention strategy, but it is not the most critical and immediate action. The potential for a sudden, life-threatening change in fetal status due to cord prolapse takes precedence over hygiene.
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