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
Explanation
Choice A rationale
Seizure activity typically presents with symptoms such as convulsions, loss of consciousness, or abnormal behavior, which are not described in the scenario.
Choice B rationale
Arrhythmia, or an abnormal heart rhythm, could potentially cause a sudden drop in oxygen saturation and cyanosis. It could also lead to a rapid response team being called.
Choice C rationale
Increased oxygen demand could potentially lead to low oxygen saturation. However, it would not typically cause cyanosis or require the rapid response team to be called unless it was associated with another condition such as heart or lung disease.
Choice D rationale
Acidosis, or a high level of acid in the body, could potentially cause low oxygen saturation. However, it would not typically cause cyanosis or require the rapid response team to be called unless it was severe or associated with another condition.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Applying warm compresses can help relieve the pain and pressure associated with acute rhinosinusitis by reducing inflammation and promoting sinus drainage.
Choice B rationale
Completing prescribed antibiotics is crucial in treating acute bacterial rhinosinusitis.
Antibiotics help eliminate the bacterial infection causing the inflammation and symptoms.
Choice C rationale
Smoking can irritate the nasal passages and exacerbate the symptoms of rhinosinusitis. Avoiding smoking can help reduce inflammation and promote healing.
Choice D rationale
Swimming, especially in chlorinated pools, can irritate the nasal passages and sinuses, potentially worsening the symptoms of rhinosinusitis. It’s recommended to avoid swimming until the condition has resolved.
Choice E rationale
Periorbital edema is not a normal finding and could indicate a complication of rhinosinusitis, such as a spread of the infection. If a client notices this symptom, they should seek medical attention.
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