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 ["mLs\/hr."]
Explanation
Answer and explanation
Step 1 is to calculate the total units of Heparin in 1 mL of the solution. This is done by dividing the total units of Heparin in the bag (40,000 units) by the total volume of the bag (500 mL). So, 40,000 units ÷ 500 mL = 80 units/mL. Step 2 is to calculate the rate at which the IV pump should be set. This is done by dividing the ordered amount of Heparin per hour (1600 units) by the units of Heparin per mL (80 units/mL). So, 1600 units/hr ÷ 80 units/mL = 20 mL/hr.
So, the correct answer is 20 mL/hr.
Correct Answer is C
Explanation
Choice A rationale:
The back of the hand is sensitive to temperature, not pressure, making it less suitable for assessing contraction intensity.
Choice B rationale:
Finger tips are sensitive and can detect small changes, but they may not cover a large enough area to accurately assess contraction intensity.
Choice C rationale:
The palm of the hand covers a larger area and can better gauge the overall firmness of the uterus.
Choice D rationale:
Finger pads are sensitive to texture, not pressure, making them less suitable for this task.
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