Which of the following interventions should a nurse implement first for a client who is at 38 weeks of gestation and has a nonstress test showing a series of late decelerations?
Elevate the client's legs.
Administer lactated Ringer's via IV bolus.
Prepare the client for a cesarean birth.
Place the client in a lateral position.
The Correct Answer is D
Choice A reason: Elevating the client’s legs does not address late decelerations, which indicate uteroplacental insufficiency. This position may reduce venous return, worsening maternal cardiac output and placental perfusion. Late decelerations require interventions to improve fetal oxygenation, such as repositioning or oxygen, not leg elevation, which is irrelevant to fetal distress.
Choice B reason: Administering lactated Ringer’s via IV bolus addresses maternal hypotension but is not the first intervention for late decelerations. Positioning improves placental perfusion immediately, while fluids take longer to act. Late decelerations reflect fetal hypoxia from reduced uteroplacental blood flow, requiring urgent repositioning to optimize circulation before secondary measures like fluids.
Choice C reason: Preparing for cesarean birth is not the first intervention for late decelerations, as intrauterine resuscitation (e.g., lateral positioning) may resolve fetal hypoxia. Cesarean is considered if decelerations persist despite interventions. Immediate surgical preparation delays reversible measures, risking unnecessary maternal morbidity while bypassing simpler methods to restore fetal oxygenation.
Choice D reason: Placing the client in a lateral position is the first intervention for late decelerations, as it relieves uterine pressure on the inferior vena cava, improving maternal cardiac output and placental perfusion. This corrects fetal hypoxia by enhancing uteroplacental blood flow, addressing the physiological cause of decelerations, per obstetric emergency protocols.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Administering an IV bolus of lactated Ringer’s is not indicated for preeclampsia without severe features, as fluid overload can exacerbate hypertension or pulmonary edema. P ओपेक्शिया involves endothelial dysfunction, and excessive fluids may worsen vascular leakage. Blood pressure and symptom monitoring are prioritized over fluid administration in non-severe cases.
Choice B reason: Misoprostol is used for labor induction or postpartum hemorrhage, not preeclampsia management. Preeclampsia requires blood pressure control and seizure prophylaxis, not cervical ripening agents. Misoprostol’s prostaglandin effects are irrelevant to preeclampsia’s pathophysiology, which involves vasoconstriction and endothelial damage, making this medication inappropriate for the condition’s treatment.
Choice C reason: Assessing blood pressure twice daily is insufficient for preeclampsia, even without severe features, as it requires frequent monitoring (every 4-6 hours) to detect progression to severe hypertension. Preeclampsia can rapidly worsen due to vascular instability, and infrequent checks risk missing critical changes, compromising maternal and fetal safety.
Choice D reason: Assessing for edema is essential in preeclampsia, as it reflects vascular leakage from endothelial dysfunction. Edema, especially in the face or hands, signals worsening disease, necessitating closer monitoring or intervention. This assessment tracks fluid retention, a key pathophysiological feature of preeclampsia, aiding in early detection of progression to severe features.
Correct Answer is C
Explanation
Choice A reason: Polyuria is not an adverse effect of epidural analgesia. Epidurals may cause urinary retention due to bladder sensation loss from nerve blockade, not increased urine output. Polyuria could reflect unrelated conditions like diabetes insipidus, but it does not align with epidural’s neurological effects on bladder function.
Choice B reason: A maternal temperature of 37.4°C (99.4°F) is within normal range and not an adverse effect of epidural analgesia. Epidurals may rarely cause fever due to immune responses, but this temperature is physiological. It does not indicate a complication requiring documentation, per obstetric monitoring standards.
Choice C reason: Hypotension is a common adverse effect of epidural analgesia, as sympathetic blockade causes vasodilation, reducing blood pressure. This can impair placental perfusion, risking fetal hypoxia. Documentation is critical to prompt interventions like fluid boluses, ensuring maternal and fetal stability, per epidural pharmacology and obstetric care protocols.
Choice D reason: A fetal heart rate of 152/min is within the normal range (110-160/min) and not an adverse effect of epidural analgesia. While epidurals may cause maternal hypotension affecting fetal perfusion, this rate indicates fetal well-being, not requiring documentation as an adverse effect, per fetal monitoring guidelines.
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