While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate during the contraction's peak, with the nadir of the decelerations occurring when the contraction end. The nurse's first priority is to:
Select one:
Insert a scalp electrode.
Notify the care provider.
Assist with amnioinfusion.
Reposition the patient.
The Correct Answer is D
a. A scalp electrode is not indicated unless there is a problem with the external monitor tracing or if further assessment of the fetal heart rate variability is needed.
b. This is important but repositioning the patient is the priority.
c. Amnioinfusion is only done if repositioning the patient does not resolve the late decelerations.
d. The nurse is observing late decelerations of the fetal heart rate, which indicate uteroplacental insufficiency and fetal hypoxia. The nurse's first priority is to reposition the patient to improve placental blood flow and oxygen delivery to the fetus. Repositioning can be done by turning the patient to her side, elevating her legs, or placing a wedge under her hip.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Massaging the client's back can help to close the "gate" for pain signals to reach the brain according to the Gate control theory of pain.
b. Administering analgesic medications addresses pain but does not directly apply the principles of the Gate control theory.
c. Placing the client on a supine position does not specifically address pain control according to the Gate control theory.
d. Repositioning onto her left side may be done for fetal well-being but does not directly apply the principles of the Gate control theory.
Correct Answer is A
Explanation
a. Dexamethasone is a corticosteroid that is given to women at risk of preterm delivery to stimulate fetal lung maturation and surfactant production.
b. Dexamethasone is not used for this purpose.
c. Dexamethasone is not used to suppress uterine contractions.
d. Dexamethasone is not used to reduce maternal and fetal tachycardia.
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