The nurse is caring for a laboring client with early decelerations and a fetal heart rate baseline of 130 with moderate variability. What will the nurse do for this client?
Notify the charge nurse to perform a vaginal exam
Promptly inform the primary care provider
Continue to monitor the client and the fetal heart rate
Reposition the client to the left side
The Correct Answer is C
A. Early decelerations are generally considered benign and not an indication for a vaginal exam unless other concerning factors are present.
B. Promptly informing the primary care provider may not be necessary for early decelerations, which are often a normal response to head compression.
C. Continuous monitoring and observation of the client and fetal heart rate are appropriate for early decelerations, especially when the baseline is reassuring and there is moderate variability.
D. Repositioning the client to the left side is a general measure for optimizing fetal oxygenation, but it may not be the priority in the case of early decelerations, which are usually benign and
related to head compression.
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Related Questions
Correct Answer is D
Explanation
A. Oxytocin is administered to enhance contractions, not to slow them down.
B. While increased blood flow through the placenta is important for fetal well-being, oxytocin is primarily used to stimulate uterine contractions.
C. Increased urinary output is not the primary effect of oxytocin; its main action is to stimulate uterine contractions.
D. Oxytocin is commonly used to induce or augment labor by stimulating contractions of the uterus.
Correct Answer is C
Explanation
A. Uterine atony is characterized by a boggy and enlarged uterus, not a firm one.
B. A cervical laceration would typically present with bleeding and possibly a deviation of the uterus from the midline, but the firm uterus suggests a different cause.
C. Continuous seepage of bright red blood, along with a firm uterus, 1 cm below the umbilicus, and midline, is indicative of retained placental fragments.
D. A urinary tract infection would not typically cause continuous bright red blood seepage from the vagina.
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