The nurse is evaluating the fetal monitor tracing of the patient who is in active labor.
Suddenly, the nurse sees the FHR drop from its baseline of 125 down to 80. The nurse repositions the mother, provides oxygen, increases intravenous fluids, and performs a vaginal exam.
The cervix has not changed.
Two minutes have passed, and the fetal heart rate remains in the 70s.
What additional nursing measures should the nurse take?
Call for help and notify the care provider.
Immediately get help and have the operating room ready.
Start Pitocin.
Insert a Foley catheter.
Repeat the uterine resuscitation.
Correct Answer : A,B
Choice A rationale
Calling for help and notifying the care provider ensures that expert medical assistance is available promptly for any emergency interventions required.
Choice B rationale
Getting help and preparing the operating room ensures readiness for an immediate cesarean section if fetal distress persists and the situation does not improve rapidly.
Choice C rationale
Starting Pitocin is inappropriate during fetal distress as it may further stress the fetus by increasing contraction frequency and intensity, potentially worsening the situation.
Choice D rationale
Inserting a Foley catheter does not address the immediate concern of fetal distress and would not provide immediate benefit in improving fetal heart rate.
Choice E rationale
Repeating uterine resuscitation measures (e.g., repositioning, oxygen, IV fluids) is essential, but if they are ineffective, additional interventions, such as preparing for possible surgical delivery, are needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
The cervix is measured in dilation, not effacement, in centimeters. Effacement is expressed in percentage, indicating the thinning of the cervix.
Choice B rationale
The cervix is 3 cm dilated, 30% effaced, and the presenting part is 2 cm above the ischial spines. This assessment provides a clear status of labor progress.
Choice C rationale
The presenting part being below the ischial spines would be recorded with a positive station, indicating descent into the pelvis, unlike this assessment.
Choice D rationale
The cervix is assessed for dilation in centimeters and effacement in percentage, with station indicating the relationship to the ischial spines.
Correct Answer is B
Explanation
Choice A rationale
Rubella vaccination is contraindicated during pregnancy due to the live virus, which poses a risk to the fetus. Administration should occur postpartum to avoid congenital rubella syndrome in the infant.
Choice B rationale
This statement is correct as rubella vaccination should be deferred until after delivery. It avoids exposure to the live virus during pregnancy, protecting fetal health.
Choice C rationale
The Tdap vaccine is recommended during each pregnancy, typically between 27 and 36 weeks gestation, to boost maternal antibodies and provide passive immunity to the newborn.
Choice D rationale
The flu vaccine is recommended during pregnancy to protect both the mother and the baby from influenza. It reduces the risk of severe illness and complications from the flu.
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