The nurse is assessing a patient in Labor with the findings in the chart: Fatal heart rate 135 with early decelerations. What action will the nurse implement?
Encourage the patient to ambulate intermittently and change positions.
Place the patient in the left lateral position and increase the oxytocin rate.
Administer oxygen 10 litters per minute via a non-rebreather mask.
Teach the patient to push when she feels the urge during contractions.
The Correct Answer is A
Choice A reason: Encouraging the patient to ambulate intermittently and change positions can help alleviate early decelerations by improving uteroplacental blood flow and promoting fatal oxygenation. Movement and position changes can reduce compression on the umbilical cord and facilitate Labor progression.
Choice B reason: Placing the patient in the left lateral position can improve uteroplacental blood flow, but increasing the oxytocin rate is not indicated based on the current findings. Early decelerations are typically not a sign of Labor dystocia requiring oxytocin augmentation.
Choice C reason: Administering oxygen via a non-rebreather mask is generally reserved for situations where there is significant fatal distress or non-reassuring fatal heart rate patterns. Early decelerations are usually benign and do not necessitate supplemental oxygen.
Choice D reason: Teaching the patient to push when she feels the urge during contractions is appropriate during the second stage of Labor. However, the current findings with early decelerations do not indicate the need for this intervention at this time. The focus should be on monitoring and managing the fatal heart rate.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Maternal hypertension, or high blood pressure, is not directly associated with precipitous Labor. While hypertension can be a concern during pregnancy, it is not a primary complication resulting from a rapid Labor process. The nurse's focus would be on other specific complications that arise from precipitous Labor.
Choice B reason: Postpartum haemorrhage is a significant risk for patients experiencing precipitous Labor. Rapid Labor can lead to excessive uterine contractions, which might cause trauma to the birth canal, including lacerations and uterine atony (failure of the uterus to contract properly after delivery). These conditions can lead to significant blood loss and necessitate close monitoring and intervention to manage and mitigate the haemorrhage.
Choice C reason: Newborn hyperglycaemia, which refers to elevated blood sugar levels in the newborn, is not related to the process of precipitous Labor. This condition is more commonly associated with maternal diabetes and is not a typical complication the nurse would monitor for in this scenario.
Choice D reason: Premature rupture of membranes, which refers to the breaking of the amniotic sac before Labor begins, is not a complication resulting from precipitous Labor. It is a condition that can precede Labor but is not caused by the rapid progression of Labor. The nurse would be more concerned with managing complications directly related to the rapid Labor and delivery process.
Correct Answer is A
Explanation
Choice A reason: The Human Papillomavirus (HPV) vaccine is typically recommended for preteens at age 11 or 12 to protect against HPV infections that can lead to certain types of cancer later in life. This vaccine is given as a series of shots, and starting the series at 11 years old is ideal for maximizing its effectiveness before any potential exposure to the virus.
Choice B reason: The Pneumococcal vaccine is generally recommended for infants, young children, and older adults, particularly those with certain health conditions. It protects against pneumococcal disease, including infections in the lungs, blood, and brain. While it is crucial for vulnerable populations, it is not typically administered to healthy 11-year-old children.
Choice C reason: The Measles vaccine is part of the MMR (Measles, Mumps, Rubella) vaccine, which is usually administered in two doses—the first dose at 12-15 months of age and the second dose at 4-6 years of age. By the time a child reaches 11 years old, they would have already received both doses of the MMR vaccine, assuming they followed the standard vaccination schedule.
Choice D reason: The Rubella vaccine is also included in the MMR vaccine, which is given in two doses during early childhood. Since the second dose is typically administered by the age of 6, an 11-year-old child would not require another dose of the Rubella vaccine if they followed the standard vaccination schedule.
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