The nurse is caring for a client at 39 weeks gestation in active labor.The client had a spontaneous rupture of membranes 2 hours ago with clear amniotic fluid noted.
The client was 7 cm at the time of SROM.
The nurse assesses the fetal heart rate monitor and identifies a fetal heart baseline of 145 bpm, with moderate variability, accelerations absent and recurrent variable decelerations.
Which of the following interventions should the nurse take? Select all that apply.
Notify the provider.
Encourage the client to ambulate in the hallway.
Reposition the patient to the left lateral position.
Perform a sterile vaginal exam.
Provide an IV fluid bolus.
Correct Answer : A,C,D,E
Choice A rationale
Recurrent variable decelerations can indicate umbilical cord compression. Notifying the provider ensures immediate intervention if necessary to address potential fetal distress and to monitor labor progression.
Choice B rationale
Ambulation is not recommended with recurrent variable decelerations. It might increase the risk of cord prolapse or other complications, further compromising fetal wellbeing.
Choice C rationale
Repositioning to the left lateral position helps improve uteroplacental blood flow and reduce cord compression, addressing the decelerations and promoting fetal oxygenation.
Choice D rationale
Performing a sterile vaginal exam can help identify any immediate issues like cord prolapse or rapid cervical changes that could impact labor management and fetal wellbeing.
Choice E rationale
Providing an IV fluid bolus can improve maternal hydration and placental perfusion, potentially alleviating the cause of variable decelerations by increasing blood flow and reducing cord compression effects. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Clapping hands to assess hearing is not a reliable method and could startle the baby for reasons unrelated to hearing ability.
Choice B rationale
While a newborn might respond to visual stimuli, this is not a definitive method to assess hearing.
Choice C rationale
Routine hearing screenings using objective tests are the best way to determine a newborn's hearing ability, providing accurate and early detection of potential hearing issues.
Choice D rationale
This statement is misleading, as some forms of hearing loss can be inherited. It's important to use accurate methods to assess newborn hearing.
Correct Answer is A
Explanation
Choice A rationale
Pelvic pain and fatigue can be indicators of endometritis, an infection of the uterine lining. It often manifests with pain, fever, and general malaise, and requires further evaluation and intervention.
Choice B rationale
Light amount of dark red lochia with a bloody odor is a normal postpartum finding. Lochia progresses through different stages, and dark red lochia, which occurs in the later stages, typically has a bloody odor.
Choice C rationale
Hematuria, or the presence of blood in the urine, is not a typical symptom of endometritis. It may indicate a urinary tract infection or other renal issues instead.
Choice D rationale
A localized area of breast tenderness may indicate mastitis, an infection of the breast tissue. It is not related to endometritis but requires attention and treatment.
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