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 B
Explanation
Choice A rationale:
Bacterial vaginosis typically presents with a thin, grayish-white discharge with a fishy odor. It does not usually cause intense itching or dyspareunia.
Choice B rationale:
Candidiasis is characterized by a thick, white, cottage cheese-like vaginal discharge, intense itching, and dyspareunia. These symptoms align with the client’s presentation.
Choice C rationale:
Genital herpes simplex usually presents with painful blisters or ulcers in the genital area, not a thick, white discharge.
Choice D rationale:
Trichomoniasis often causes a frothy, yellow-green discharge with a fishy smell. Itching can occur, but the discharge is not typically thick and white.
Correct Answer is D
Explanation
Choice A rationale:
Follicle-stimulating hormone is important for the development of the ovarian follicles, but it’s not the most important for maintaining the female reproductive organs.
Choice B rationale:
Androgens are male hormones and are not the most important for developing and maintaining the female reproductive organs.
Choice C rationale:
Progesterone is important for maintaining the endometrium, but it’s not the most important.
Choice D rationale:
Estrogen is the most important hormone for developing and maintaining the female reproductive organs. It promotes the growth and development of the female secondary sexual characteristics and the growth of the endometrium.
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