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.

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is ["300"]

Explanation

Step 1:

4 grams ÷ 20 grams × 500 mL = 100 mL

Step 2:

100 mL ÷ 20 minutes × 60 minutes/hour = 300 mL/hour

Answer:

300 mL/hour

A. When the placental site has healed. B. When ovulation resumes. C. Six to eight weeks after birth. D. Four weeks after birth.

Correct Answer is C

Explanation

Choice A rationale

While the healing of the placental site is a part of the postpartum recovery process, it does not directly correlate with the return of menstruation.

Choice B rationale

Ovulation does need to resume for menstruation to return, but the timing of ovulation resuming postpartum can vary greatly among individuals and does not provide a specific timeframe.

Choice C rationale

For a postpartum client who is formula-feeding her new baby, menstruation typically resumes six to eight weeks after birth.

Choice D rationale

While it is possible for menstruation to resume four weeks after birth, this is less common. The typical timeframe for the return of menstruation for a postpartum client who is formula- feeding is six to eight weeks.

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The nurse observes on the fetal monitor that a laboring client has a variable deceleration. What action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes magnesium sulfate 4 grams intravenously (IV) to be infused over 20 minutes for a client with preeclampsia. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse program the infusion pump?

Correct Answer is ["300"]

Explanation

A postpartum client who is formula-feeding her new baby inquires about when she should expect her menstruation to resume.What should the nurse inform the client?

Correct Answer is C

Explanation

A mother inquires about what to use when changing her newborn’s diaper. What should the nurse recommend to this mother?

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The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has risen from 110/60 mmHg to 140/90 mmHg.Which nursing protocol is of the highest priority?