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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason: Holding their head upright and sitting unsupported are signs that an infant may be ready for solid foods. These motor skills indicate that the baby has enough control to handle swallowing food safely.

Choice B reason: Pushing food out with their tongue is known as the tongue-thrust reflex, and it is a sign that the infant may not be ready for solid foods yet. This reflex prevents choking and generally diminishes between 4 and 6 months of age.

Choice C reason: Grasping small objects and not letting go demonstrates that the baby has developed fine motor skills, which are also important for starting solid foods. However, this alone does not determine readiness.

Choice D reason: Being between 4 and 6 months old is an appropriate age range for introducing solid foods, as long as other readiness signs are also present. Age alone is not the sole indicator of readiness for solid foods.

A. Inform the patient that they are in latent Labor. B. Initiate Labor augmentation. C. Prepare the patient for a caesarean delivery. D. Anticipate admission to the Labor and delivery unit.

Correct Answer is A

Explanation

Choice A reason: Informing the patient that they are in latent Labor is appropriate in this situation. Latent Labor, also known as early Labor, is characterized by cervical dilation of up to 3 cm and mild contractions that may last for several hours or even days. It is important to educate the patient about the early stages of Labor and what to expect as it progresses.

Choice B reason: Initiating Labor augmentation is not necessary at this point. Labor augmentation is typically used when Labor is not progressing adequately. In this case, the patient is in the early stages of Labor, and there is no indication that augmentation is needed.

Choice C reason: Preparing the patient for a caesarean delivery is not warranted based on the information provided. The patient's condition does not suggest any immediate need for a caesarean section, and the Labor is still in its early stages.

Choice D reason: Anticipating admission to the Labor and delivery unit may not be required at this stage. Since the patient is in latent Labor, they may be advised to stay at home until Labor progresses further and the contractions become more intense and frequent. This helps reduce unnecessary hospital admissions and allows the patient to be more comfortable in their home environment.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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