What is the priority nursing action when caring for a client who has had an amniotomy and the fetal heart rate immediately decreases from 140 to 80 beats/min?
Administer oxygen.
Increase the intravenous fluids.
Inspecting the vagina.
Placing the client in the knee-chest position.
The Correct Answer is C
Choice A rationale
Administering oxygen is an appropriate intervention for fetal distress (normal FHR is 110-160 beats/min), but the immediate, precipitating cause of this sudden, profound bradycardia after amniotomy must first be determined. Oxygen is secondary to resolving the likely mechanical issue of a prolapsed cord.
Choice B rationale
Increasing intravenous fluids (IVFs) may improve maternal hydration and thus placental perfusion, which can sometimes help with mild FHR decelerations. However, it is not the immediate priority for a severe, acute drop to 80 beats/min after membrane rupture, which strongly suggests umbilical cord prolapse.
Choice C rationale
A sudden, severe FHR drop after amniotomy is highly indicative of umbilical cord prolapse, where the cord drops below the presenting part and is compressed. Inspecting the vagina (or performing a sterile vaginal examination) is the priority to visually or digitally confirm the presence of a prolapsed cord so immediate action can be taken to relieve compression.
Choice D rationale
Placing the client in the knee-chest position (or Trendelenburg) is done after confirming cord prolapse to use gravity to move the fetus off the compressed cord. The most immediate action is to diagnose the cause of the distress, as time is critical to prevent severe fetal hypoxia and injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["67"]
Explanation
Step 1 is to determine the volume of solution (in mL) that contains the ordered dose (4 grams) of magnesium sulfate:. 7 mg ÷ (2 mg/5mL). (1000 mL ÷ 60 grams) × 4 grams = 66.666. mL.
Step 2 is to round the answer to the nearest whole number:. 67 mL/hr. Answer 67 mL/hr.
Correct Answer is A
Explanation
Choice A rationale
Rho(D) immune globulin, or RhoGAM, is an exogenous preparation of anti-D antibodies that bind to any fetal Rh-positive red blood cells that enter the maternal circulation, effectively clearing them before the mother's immune system recognizes the D antigen and mounts an immune response. This prevents sensitization, allowing the woman to have unlimited subsequent Rh-positive children without the risk of developing hemolytic disease of the fetus and newborn (HDFN).
Choice B rationale
The recommendation is not limited to only two children if Rho(D) immune globulin is administered correctly. The medication provides passive immunity to prevent the mother from producing her own anti-D antibodies, which are the cause of HDFN in subsequent Rh-positive fetuses. Administration within 72 hours postpartum and often prophylactically around 28 weeks gestation is standard practice.
Choice C rationale
If Rh sensitization has occurred in a prior pregnancy or due to other exposure and Rho(D) immune globulin was not given, the mother's immune system will have produced anti-D antibodies. These immunoglobulin G (IgG) antibodies can cross the placenta and affect all subsequent Rh-positive fetuses, not just the next one, potentially causing fetal hemolysis and severe anemia.
Choice D rationale
Hemolytic disease of the fetus and newborn (HDFN) is determined by the fetal Rh status, specifically the presence of the D antigen on the fetal red blood cells, which is an autosomal dominant trait. The sex of the fetus (male or female) is genetically unrelated to the inheritance of the Rh factor and does not influence the severity or occurrence of the Rh incompatibility reaction.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.