The nurse is caring for a laboring client. The nurse observes that there are variable decelerations. What is the nurse's priority action?
Assist the client to change positions
Promptly inform the primary care provider
Advocate for the client to have a vaginal examination
Continue to monitor the client and the fetal heart rate
The Correct Answer is A
A. Changing the client's position, especially if there's a cord compression causing variable decelerations, is a priority intervention to alleviate the decelerations.
B. Informing the primary care provider is important, but immediate action to address the decelerations should be taken first.
C. Vaginal examination is not the immediate priority when variable decelerations are observed; interventions to improve fetal oxygenation are more critical.
D. Continuous monitoring is essential, but addressing the cause of the variable decelerations by changing the client's position is the immediate action.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A FHR baseline of 125 is within the normal range for a fetal heart rate.
B. A temperature of 99.9°F is a mild elevation and may not be an immediate concern.
C. Blood pressure of 142/90 may be elevated but may not require immediate action unless associated with other concerning symptoms.
D. Contractions lasting 45-60 seconds are prolonged and may lead to decreased fetal oxygenation. This finding should be reported immediately to the charge nurse.
Correct Answer is A
Explanation
A. A classical incision increases the risk of uterine rupture during labor, and a vaginal birth is not typically recommended due to this risk.
B. The type of incision, not the term of the subsequent birth, is the primary consideration for deciding on a mode of delivery.
C. A classical incision is associated with an increased risk of complications, not a decreased risk.
D. The recommendation for a vaginal birth after cesarean (VBAC) depends on factors such as the type of uterine incision and other clinical considerations, not just the time interval.
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