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 A
Explanation
Choice A rationale:
Cervical dilation is the major change occurring during the first stage of labor. This stage begins with the onset of labor and ends when the cervix is fully dilated.
Choice B rationale:
Fetal movement through the birth canal primarily occurs during the second stage of labor, not the first.
Choice C rationale:
Placental separation occurs during the third stage of labor, after the baby is born.
Choice D rationale:
Regular contractions do occur during the first stage of labor, but they are not the major change. The major change is cervical dilation.
Correct Answer is A
Explanation
Choice A rationale:
Physiologic anemia due to hemoglobin decrease does not cause dizziness when lying flat.
Choice B rationale:
A 50% increase in blood volume does not directly cause dizziness when lying flat.
Choice C rationale:
The gravid uterus can compress the vena cava when the woman lies flat, reducing blood flow to the heart and causing dizziness.
Choice D rationale:
Pressure of the presenting fetal part on the diaphragm can cause shortness of breath, but not dizziness.
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