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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Placing fingers across the uterus is not a standard technique for assessing the uterine fundus postpartum. Palpation is typically performed on the abdomen.
B. Placing a gloved hand just above the symphysis pubis is more related to assessing descent and engagement of the fetal head during labor, not uterine fundal height.
C. Palpating the abdomen while feeling the uterine fundus allows the nurse to assess the fundal height, tone, and position.
D. Massaging the fundus vigorously to expel blood clots is not a recommended practice; gentle massage is performed to assess tone and firmness.
Correct Answer is A
Explanation
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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