A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?

Administer oxygen using a nonrebreather mask.

Elevate the client's legs.

Place the client in the lateral position.

Increase the rate of maintenance IV infusion.

Answer and Explanation

The Correct Answer is C

A)   Administer oxygen using a nonrebreather mask: While oxygen may be necessary if there are signs of fetal distress, the priority action in this situation is to reposition the client and relieve potential cord compression.
B)   Elevate the client's legs: Elevating the client's legs is not the most appropriate action in this situation and may not address the cause of the decelerations.
C)   Place the client in the lateral position: This is the correct answer. The described pattern of the fetal heart rate (slowdown after the start of a contraction with the lowest rate occurring after the peak of the contraction) suggests late decelerations, which are often caused by uteroplacental
insufficiency or cord compression. Placing the client in the lateral position can help alleviate potential compression of the umbilical cord and improve fetal oxygenation.
D)   Increase the rate of maintenance IV infusion: Increasing the IV infusion rate may not be the most appropriate action for late decelerations. Repositioning the client is the priority in this situation.

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Correct Answer is B

Explanation

A. Maintain the client in the lithotomy position: The lithotomy position is not typically

maintained during the active phase of labor. It is used during the pushing stage (second stage) of labor.
B. Encourage the client to empty her bladder every 2 hr: A full bladder can impede fetal descent and progress during labor, so encouraging the client to empty her bladder regularly is essential.
C. Remind the client to bear down with each contraction: Bearing down during the active phase of labor is not appropriate, as it may lead to premature pushing and cervical swelling.
D. Perform vaginal examinations frequently: Frequent vaginal examinations can increase the risk of infection and should be minimized during labor.

A. "You should take a deep, cleansing breath and breathe naturally." B. "You should go ahead and push as hard as you can to assist the delivery." C. "You should try to blow or pant as the baby is being born to help avoid a toorapid birth." D. "You should try to perform slowpaced breathing patterns."

Correct Answer is C

Explanation

A: Taking deep, cleansing breaths and breathing naturally is not the appropriate technique during the crowning phase of labor, as it can increase the risk of rapid birth and potential perineal trauma.

C: During a precipitous labor with the baby's head crowning, the nurse should encourage the mother to perform blowing or panting breaths during contractions. This technique helps to slow down the delivery process and allows the perineum to stretch gradually, reducing the risk of tearing or other trauma.

B: In the case of precipitous labor, actively pushing as hard as possible can increase the risk of rapid birth and potential complications for both the mother and the baby.

D: Slowpaced breathing patterns are not recommended during the crowning phase of labor, as they may not effectively control the birth process.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching?

A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?

A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make?

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?

A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone (Cervidil) gel. Which of the following statements should the nurse include in the teaching?

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?