When caring for a laboring mother, late decelerations are noted on the fetal heart rate monitor. What actions should the nurse take? (Select all that apply
Turn the patient to her side.
Provide 2-3 liters of oxygen via mask
Notify the health care provider.
Stop the oxytocin
Correct Answer : A,B,C,D
A. Turning the patient to her side can improve placental blood flow and alleviate pressure on the umbilical cord, which is often the cause of late decelerations.
B. Providing oxygen can help improve oxygenation to the fetus, especially if the decelerations are due to uteroplacental insufficiency.
C. Notifying the healthcare provider is essential to address the situation promptly and determine whether further interventions or a change in labor management is necessary.
D. Stopping oxytocin can reduce uterine contractions and prevent further stress on the fetus, especially if the late decelerations are linked to uterine hyperstimulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Transient tachypnea of the newborn (TTN) is a common condition in full-term infants, particularly those born via C-section, and is characterized by rapid breathing (tachypnea), nasal flaring, and mild respiratory distress within the first few hours after birth. The condition typically resolves within 48-72 hours.
B. Respiratory distress syndrome (RDS) usually occurs in premature infants, and the symptoms described do not match this condition.
C. Meconium aspiration syndrome is usually associated with meconium-stained amniotic fluid and typically presents with more severe respiratory distress and other signs of obstruction.
D. A tracheoesophageal fistula would present with more severe respiratory symptoms, such as choking and coughing, and is not typically characterized by tachypnea alone.
Correct Answer is C
Explanation
A. Genetic testing is not necessary to determine if the twins are identical. Identical twins come from the same egg, while fraternal twins come from separate eggs.
B. The size difference alone does not determine whether twins are identical or fraternal.
C. Dizygotic twins (fraternal twins) are always of different sexes. This is because they are fertilized by two separate sperm and develop from two separate eggs.
D. Monozygotic twins (identical twins) occur when one fertilized egg splits into two embryos. The fact that they are different sexes rules out the possibility of monozygotic twins.
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