A client is in active labor.
Checking the EFM tracing, the nurse notes variables that are abnormal.
What would be the nurse's first nursing intervention?
Obtain assistance to check for a compressed umbilical cord.
Prepare the woman for an emergency cesarean birth.
Document the finding.
Help the woman change positions.
The Correct Answer is D
Choice A rationale:
Checking for a compressed umbilical cord is important as it can cause fetal distress. However, it’s not the first step in response to abnormal EFM tracing.
Choice B rationale:
Preparing for an emergency cesarean birth might be necessary if the abnormality persists and indicates fetal distress. But it’s not the immediate first step.
Choice C rationale:
Documenting the finding is part of the nursing process, but immediate interventions to address the abnormality take precedence.
Choice D rationale:
Helping the woman change positions can relieve pressure on the umbilical cord, potentially resolving the abnormality. This is often the first intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Checking for a compressed umbilical cord is important as it can cause fetal distress. However, it’s not the first step in response to abnormal EFM tracing.
Choice B rationale:
Preparing for an emergency cesarean birth might be necessary if the abnormality persists and indicates fetal distress. But it’s not the immediate first step.
Choice C rationale:
Documenting the finding is part of the nursing process, but immediate interventions to address the abnormality take precedence.
Choice D rationale:
Helping the woman change positions can relieve pressure on the umbilical cord, potentially resolving the abnormality. This is often the first intervention.
Correct Answer is B
Explanation
Swallowing a preprocedure sedative is not typically required for an amniocentesis. Sedatives can affect the mother and the fetus, and are usually avoided unless absolutely necessary.
Choice B rationale:
Emptying the bladder is important before an amniocentesis. A full bladder can push against the uterus, increasing the risk of puncturing the bladder during the procedure.
Choice C rationale:
Showering with an antiseptic scrub is not typically required before an amniocentesis. The area of the abdomen where the needle will be inserted is usually cleaned with an antiseptic by the healthcare provider.
Choice D rationale:
Lying on the left side is not typically required for an amniocentesis. The procedure is usually performed with the woman lying on her back.
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