The nurse observes on the fetal monitor that a laboring client has a variable deceleration. What action should the nurse implement first?
Administer oxygen via facemask.
Change the client’s position.
Turn off the oxytocin infusion.
Assess cervical dilatation.
The Correct Answer is B
Choice A rationale
Administering oxygen via facemask is a common intervention for variable decelerations, but it is not the first action that should be taken.
Choice B rationale
Changing the client’s position is the recommended first action for variable decelerations. Repositioning the mother, such as moving her to a lateral or knee-chest position, can relieve potential cord compression and improve fetal oxygenation.
Choice C rationale
Turning off the oxytocin infusion is another intervention for variable decelerations, but it is not the first action that should be taken.
Choice D rationale
Assessing cervical dilation is not the first action that should be taken in response to variable decelerations.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Abruptio placenta is a condition where the placenta prematurely separates from the uterus. It typically presents with symptoms such as vaginal bleeding, back pain, and frequent contractions. However, the symptoms described by the client do not align with this condition.
Choice B rationale
Chorioamnionitis is an infection of the membranes surrounding the fetus and is associated with prolonged labor. Symptoms include fever, abdominal pain, and fetal tachycardia. The client’s symptoms of pain when the baby moves, a high temperature, and severe abdominal or uterine tenderness on palpation align with this condition.
Choice C rationale
Round ligament strain is a common cause of pain during pregnancy, particularly in the second trimester. It is caused by the stretching of the round ligaments that support the uterus.
However, it does not cause fever or severe abdominal tenderness.
Choice D rationale
While a viral infection could potentially cause a fever, it would not typically cause severe abdominal or uterine tenderness specifically when the baby moves.
Correct Answer is B
Explanation
Choice A rationale
Cervical dilation is a sign of labor, but a dilation of 1 cm alone does not confirm active labor. It could be the early phase of labor or false labor.
Choice B rationale
Contractions that decrease with walking are typically associated with false labor. In true labor, contractions usually get stronger regardless of activity level.
Choice C rationale
While 2+ pitting edema in the lower extremities can be seen in pregnancy, it is not a reliable indicator of labor. It could be due to fluid retention or other conditions.
Choice D rationale
The status of the membranes (intact or ruptured) does not necessarily indicate whether a woman is in labor. Some women may experience membrane rupture before labor begins.
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