The fetal monitor indicates that a patient is having contractions every three to four minutes with late fetal decelerations.Which action should the nurse take first?
Notify the health care provider.
Position the patient in a left lateral position.
Increase the patient’s intravenous rate.
Provide the patient with oxygen via a face mask.
The Correct Answer is B
The correct answer is choice B. Position the patient in a left lateral position. This is because late fetal decelerations indicate uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen to the fetus. By positioning the patient on her left side, the blood flow to the placenta and the fetus is improved.
Choice A is wrong because notifying the health care provider is not the first action that the nurse should take. The nurse should first intervene to correct the cause of fetal distress and then inform the provider.
Choice C is wrong because increasing the patient’s intravenous rate may not help with uteroplacental insufficiency. It may also cause fluid overload or pulmonary edema in the patient.
Choice D is wrong because providing the patient with oxygen via a face mask is not the most effective way to increase fetal oxygenation. Oxygen therapy may be used as an adjunct to other interventions, but it is not sufficient by itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A nonstress test (NST) is a test in pregnancy that measures fetal heart rate and reaction to movement.Your pregnancy care provider performs a nonstress test to make sure the fetus is healthy and getting enough oxygen.It’s safe and painless, and gets its name because it puts no stress (nonstress) on you or the fetus.
Choice A is wrong because a nonstress test does not measure the mother’s ability to tolerate the discomfort of labor.A stress test is a different procedure that involves stimulating contractions and monitoring how the fetus responds.
Choice B is wrong because a nonstress test does not measure fetal lie, which is the position of the fetus in the uterus.
Fetal lie is usually determined by ultrasound or physical examination.
Choice D is wrong because a nonstress test does not measure maternal readiness for labor.A nonstress test typically happens after 28 weeks of pregnancy, when fetal heart rate starts reacting to movements.
Maternal readiness for labor is assessed by other factors, such as cervical dilation and effacement.
Correct Answer is A
Explanation
The correct answer is choice A. The patient has heart disease, and the antibiotics will decrease the risk to her fetus of developing endocarditis.Endocarditis is an infection of the inner lining of the heart and valves, which can be caused by bacteria entering the bloodstream during labor and delivery.Patients with mitral valve prolapse (MVP) are more prone to develop endocarditis because their valve leaflets are floppy and do not close tightly, creating a site for bacterial attachment.Antibiotics can help prevent this complication by killing the bacteria before they reach the heart.
Choice B is wrong because pericarditis is an inflammation of the outer layer of the heart, not the inner lining or valves.It is not related to MVP or bacterial infection.
Choice C is wrong because chorioamnionitis is an infection of the membranes and fluid that surround the fetus, not the heart.It is usually caused by bacteria ascending from the vagina or cervix, not from the bloodstream.
Choice D is wrong because delivering post-term does not increase the risk of systemic infection for the fetus.Systemic infection means infection that affects multiple organs or systems in the body, not just one specific site.
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