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 it is true that the ointment can help prevent certain types of infections, it is not specifically intended to prevent herpes infection. Herpes is a viral infection, and the ointment is an antibiotic, which is used to prevent bacterial infections.
Choice B rationale
The primary purpose of eye ointment is to protect newborns from serious eye infections caused by common bacteria. Mothers who have a sexually transmitted infection (STI) can pass it to their newborns during childbirth, putting them at risk for an eye infection known as ophthalmia neonatorum (ON)3.
Choice C rationale
The ointment does not serve to clear the infant’s vision. It is applied to the eyes to prevent bacterial infections, not to improve or alter the infant’s vision.
Choice D rationale
The ointment is not used to dilate the pupil to visualize the red reflex. The red reflex is a reflection from the lining of the eye that is often observed when looking at the pupil, but this is not related to the application of the ointment.

A. Immunocompromised children can be given a live virus vaccine. B. Children with febrile illness should not receive a vaccine. C. Second doses of vaccines can be given to children with prior allergic reactions. D. Breastfed children cannot receive a vaccine until after the introduction of solid foods. E. Breastfed children cannot receive a vaccine until after the introduction of solid foods.

Correct Answer is B

Explanation

Choice A rationale
Immunocompromised children are generally not given live virus vaccines due to the risk of developing the disease the vaccine is meant to prevent.
Choice B rationale
This is the correct statement. If a child has a fever or is ill, vaccination may be postponed.
Choice C rationale
Second doses of vaccines are generally not given to children who have had allergic reactions to the first dose.
Choice D rationale
Breastfeeding does not interfere with the effectiveness of vaccines. In fact, breastfeeding can enhance the response to certain vaccine antigens.

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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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Correct Answer is B

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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?