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.
Assess cervical dilatation.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
Choice A rationale
Both mother and daughter shedding tears of joy and gratitude may not necessarily indicate a healthy psychosocial adaptation. While it could be a sign of relief or happiness, it could also be a response to stress or fear.
Choice B rationale
The mother expressing her full support for her daughter can be a positive sign of psychosocial adaptation. Support from family members can play a crucial role in coping with and adapting to health-related challenges.
Choice C rationale
The mother appearing sad does not necessarily indicate a healthy psychosocial adaptation. It could be a normal reaction to her daughter’s discomfort, but it could also suggest that she is struggling to cope with the situation.
Choice D rationale
The patient giving birth to a healthy baby boy is not relevant to the question as it does not provide information about the psychosocial adaptation of the mother or the daughter.
Choice E rationale
The mother commending her daughter can be a positive sign of psychosocial adaptation. Positive reinforcement can help individuals cope with challenging situations and foster a sense of self-efficacy.
Choice F rationale
Both mother and daughter gently touching the baby’s cheek is not relevant to the question as it does not provide information about the psychosocial adaptation of the mother or the daughter.
Correct Answer is B
Explanation
Choice A rationale
While contact precautions can be important in managing some infections, they are not the primary reason for hospitalization in the case of PID891011.
Choice B rationale
Hospitalization for PID is often recommended for the administration of a supervised parenteral antibiotic protocol. This allows for the direct administration of antibiotics into the bloodstream, which can be more effective in severe cases.
Choice C rationale
The Jarisch-Herxheimer reaction is a reaction to endotoxin-like products released by the death of harmful microorganisms within the body during antibiotic treatment. It is not a primary reason for hospitalization in the treatment of PID891011.
Choice D rationale
While the collection of serial anaerobic cultures of vaginal discharge can be part of the diagnostic process for PID, it is not the primary reason for hospitalization.
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