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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Obtaining blood cultures is not the first action to take in this situation. Blood cultures would be used to identify a bloodstream infection, which is not indicated by the client’s current symptoms.
Choice B rationale
Covering the lesion with a dressing is not the appropriate action. Herpes lesions are highly contagious, and covering them does not eliminate the risk of transmission during vaginal delivery.
Choice C rationale
Administering penicillin is not the appropriate action. Penicillin is an antibiotic used to treat bacterial infections, not viral infections like herpes.
Choice D rationale
Preparing for a cesarean section is the correct action. A cesarean section is recommended for women with active genital herpes lesions or prodromal symptoms at the time of labor to prevent transmission of the virus to the newborn during delivery.
Correct Answer is C
Explanation
Choice A rationale
A heart rate of 58 beats/minute is within the normal range for adults, including those who have recently given birth. Therefore, there is no need to report this to the healthcare provider.
Choice B rationale
While assessing for excessive lochia is important in postpartum care, there is no indication from the given vital signs that this is necessary.
Choice C rationale
The vital signs provided are all within normal ranges for a postpartum patient. Therefore, the appropriate action would be to document these findings in the patient’s record.
Choice D rationale
There is no indication from the given vital signs that the patient has a fever or pain, so administering a PRN dose of acetaminophen is not necessary.
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