The nurse is caring for a multiparous client who is in labor and observes a fetal heart rate (FHR) that decreases with the peak of a contraction and returns to baseline in 30 seconds. Which action should the nurse implement?

Turn the client to her side.

Perform a sterile vaginal exam.

Administer oxygen via facemask

Call the healthcare provider (HCP)

Answer and Explanation

The Correct Answer is B

Rationale:

A. Turn the client to her side: Turning a client to her side is effective for relieving variable decelerations caused by cord compression, but the FHR is characteristic of early decelerations, which are usually benign and associated with fetal head compression.

B. Perform a sterile vaginal exam: Early decelerations often occur when the fetal head is descending into the birth canal, indicating progress in labor. Performing a sterile vaginal exam helps assess cervical dilation and fetal station to determine labor progression, which is the most appropriate next action.

C. Administer oxygen via facemask: Oxygen is indicated for late or variable decelerations associated with fetal hypoxia, but early decelerations are typically benign and do not require oxygen administration.

D. Call the healthcare provider (HCP): Early decelerations are a normal physiologic response during labor. Immediate notification of the HCP is not required unless the pattern changes or other concerning signs develop.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

Rationale:

Weight 35 lbs (15.87 kg): Weight is appropriate for a 24-month-old, indicating adequate growth and nutrition. Growth trends should continue to be monitored but currently show no concern.
Toddler speaks in 3 to 4 word sentences: Speech is appropriate for developmental age, indicating normal language and cognitive development. Age-appropriate communication supports healthy social and cognitive growth.
Bottle habit: Bottle provided at nap and bedtime: Prolonged bottle use increases the risk of dental caries and otitis media. Nighttime bottles contribute to poor oral hygiene and may worsen ear infections. Intervention includes education on limiting bottles and transitioning to cups.
Blood pressure 90/40 mm Hg: Blood pressure falls within expected range for a toddler. No signs of hypotension or cardiovascular compromise are present. Routine monitoring is sufficient.
Temperature 102.6° F (39.7° C) axillary: Fever indicates an active infection requiring monitoring and possible treatment. High temperatures can increase metabolic demand and dehydration risk. Nurse should assess for signs of worsening illness and educate parents on fever management.
Diaper count in 24 hour period 6 to 8 with urine: This indicates adequate hydration and normal renal function. Urine output is within expected limits for age and fluid intake. No interventions are required related to hydration status.

Correct Answer is {"dropdown-group-1":"A"}

Explanation

Rationale for Correct Choice

Interrupting feeding if the infant raises their eyebrows: Infants with a submucous cleft palate are at increased risk for aspiration due to abnormal palate structure. Observing subtle cues, such as raising eyebrows or coughing, and pausing the feeding helps prevent formula or saliva from entering the airway.

Rationale for Incorrect Choices

Waiting until the end of each feeding to burp: Delaying burping can increase the risk of aspiration and discomfort, as air swallowed during feeding may cause regurgitation or vomiting in infants with cleft palate.
Placing the infant in a reclining position at 45 degrees: Reclining can worsen the risk of aspiration. The infant should be positioned upright or semi-upright to facilitate safe swallowing and reduce airway compromise.

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The nurse is caring for a multiparous client who is in labor and observes a fetal heart rate (FHR) that decreases with the peak of a contraction and returns to baseline in 30 seconds. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse is performing an assessment on the toddler. For each assessment finding, click to indicate whether the findings from the assessment should be a concern or not a concern to the nurse. Each row must have only one response option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

Correct Answer is {"dropdown-group-1":"A"}

Explanation

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