A laboring client has a variable deceleration on the fetal monitor.
What is the first action that the nurse should take?

Administer oxygen via facemask.

Turn off the oxytocin infusion.

Change the client’s position.

Assess cervical dilatation.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Administering oxygen via a facemask is an intervention that can be used if the baby shows signs of distress or if the decelerations do not improve with other interventions. However, it is not the first action that should be taken.
Choice B rationale
Turning off the oxytocin infusion could be an appropriate action if the mother is receiving oxytocin and the baby is showing signs of distress. However, it is not the first action that should be taken.
Choice C rationale
Changing the client’s position is the correct first action for variable decelerations. This can relieve potential cord compression and improve fetal oxygenation.
Choice D rationale
Assessing cervical dilation is an important part of monitoring labor progress, but it is not the first action that should be taken in response to variable decelerations.

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Correct Answer is B

Explanation

Choice A rationale
While assessing parenting skills is important in general, in this specific situation, the parent has expressed a fear of needles which is preventing them from being able to administer the insulin injections. Therefore, assessing parenting skills would not directly address the issue at hand.
Choice B rationale
If the child is capable and comfortable with administering their own insulin injections, this could be a viable solution to the problem. It is not uncommon for children, especially those who are older or more mature, to take over the administration of their own insulin injections. Choice C rationale
Encouraging the parent to handle the needles may be helpful, but if the parent has a strong fear of needles, this may not be a feasible solution. It’s important to respect the parent’s fear and find alternative solutions.
Choice D rationale
Asking if there is someone else who can help with the injections could potentially be a solution, but it would depend on the family’s situation and whether there is another person who is willing and able to help.

A. Her vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale. B. She was assisted to the bathroom where she voided 150 mL of clear yellow urine. C. Lochia rubra is moderate with small clots, no foul odor noted D. The fundus is firm at the umbilicus. E. The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis. F. There is no pain, redness, or swelling in the calves. G. A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag. H. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

Correct Answer is ["A","B","C","D","E","F","G","H"]

Explanation

Step 1: The patient’s vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.

Step 2: She was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra is moderate with small clots, no foul odor noted. The fundus is firm at the umbilicus. The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis. There is no pain, redness, or swelling in the calves.

Step 3: A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

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A laboring client has a variable deceleration on the fetal monitor. What is the first action that the nurse should take?

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The nurse is instructing the parent of a 10-year-old child newly diagnosed with type 1 diabetes mellitus (DM) on how to administer subcutaneous insulin injections. The parent expresses a fear of needles and is unable to perform the procedure. What intervention should the nurse implement?

Correct Answer is B

Explanation

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Correct Answer is ["A","B","C","D","E","F","G","H"]

Explanation

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A laboring client has a variable deceleration on the fetal monitor.
What is the first action that the nurse should take?