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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Related Questions
Correct Answer is C
Explanation
Choice A rationale
While breastfeeding more frequently can be beneficial for the mother-infant bonding and milk production, it does not directly address the infant’s weight loss.
Choice B rationale
Monitoring the neonate’s stool and urine output for the last 24 hours can provide information about the infant’s hydration status. However, it does not directly address the concern of weight loss.
Choice C rationale
It is normal for newborns to lose some weight in the first few days after birth. This is often due to the loss of excess fluid. A weight loss of up to 10% of the birth weight is generally considered normal in the first week.
Choice D rationale
While it’s important to verify the accuracy of the weight measurement, informing the healthcare provider is not the immediate action required if the weight loss is within the normal range.
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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