A nurse is analyzing a fetal heart monitor strip and identifies a sinusoidal fetal heart rate pattern, which has been occurring for 30 min. Which of the following actions should the nurse take at this time?
Decrease the client's IV fluids
Prepare the client for an emergent birth.
Turn the client to a supine position
Document the findings.
The Correct Answer is B
A) Decrease the client's IV fluids:
Sinusoidal fetal heart rate patterns are concerning and typically indicate severe fetal distress, which is often associated with conditions such as fetal anemia, hypoxia, or central nervous system (CNS) damage. Decreasing IV fluids is not an appropriate response to a sinusoidal pattern. The primary focus should be on fetal well-being, not fluid management, in this situation.
B) Prepare the client for an emergent birth:
This pattern is typically associated with severe fetal compromise and is an ominous sign. Immediate intervention is required, and emergent delivery may be necessary to prevent further fetal distress and potential harm. The nurse should promptly notify the healthcare provider and prepare the client for an emergency cesarean delivery or other urgent interventions.
C) Turn the client to a supine position:
The supine position is not recommended for managing fetal distress, as it may decrease uterine blood flow and worsen the situation, especially if the fetus is experiencing hypoxia. The appropriate intervention for addressing a sinusoidal heart rate pattern is not repositioning the client in a supine position, but rather preparing for emergency delivery and providing immediate support to stabilize both mother and fetus.
D) Document the findings:
While it is important to document any fetal heart rate pattern, sinusoidal patterns require immediate action. Documentation alone is not sufficient in this case, as it does not address the potential life-threatening situation for the fetus. The nurse should not delay action, and the focus should be on preparing for emergency birth and notifying the healthcare provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) "There are specific pain management options that you need to use":
It’s important to respect the client's autonomy and work collaboratively to explore pain management options that align with their cultural values and medical safety. A more open, client-centered approach would be more beneficial.
B) "We will work with you to incorporate the practices that are safe for you and your fetus.":
This statement acknowledges the client's cultural preferences while ensuring that safety is the priority. The nurse is offering to collaborate with the client to explore pain management options that align with their values, within the scope of what is medically safe for both the mother and the fetus. It promotes a partnership approach, which is critical in maternity care.
C) "You will need to discuss this with the provider.":
While the provider may ultimately be involved in deciding specific pain management options, this statement dismisses the nurse's role in supporting the client’s cultural preferences. Nurses can play an active role in initiating and facilitating these conversations with clients and helping them express their preferences to the provider. It is not solely the provider's responsibility.
D) "It is better to use pain management options that have been researched.":
While evidence-based practices are important, this statement could be seen as dismissive of the client's cultural preferences. It fails to address the importance of individualized care and overlooks the possibility of integrating safe, culturally relevant pain management practices alongside researched methods. A balanced approach that respects both cultural values and medical safety is crucial.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"},"H":{"answers":"B"},"I":{"answers":"B"}}
Explanation
- Apply petrolatum to penis with each diaper change: Applying petrolatum prevents the healing circumcision site from adhering to the diaper, reducing pain and promoting proper healing.
- Use a diaper barrier cream that contains zinc oxid: Zinc oxide is used for diaper rash treatment but is not routinely necessary. It may interfere with circumcision healing by creating a barrier that retains moisture.
- Use alcohol-based baby wipes on the soiled genital area: Alcohol-based wipes can be too harsh on a newborn’s delicate skin and may cause irritation, especially on the healing circumcision site.
- Fold the diaper below the umbilical cord at all times: Folding the diaper below the umbilical cord keeps the area dry and exposed to air, promoting natural drying and reducing the risk of infection.
- Apply alcohol to the umbilical stump with a diaper change: Alcohol was previously used to dry the cord, but current guidelines recommend keeping it clean and dry, allowing it to fall off naturally.
- Use a soft-bristled brush with mild shampoo to wash the head: A soft-bristled brush helps loosen cradle cap (seborrheic dermatitis), preventing buildup of flaky skin without causing irritation.
- Bathe in a shallow warm tub every other day: Full immersion bathing should be avoided until the umbilical cord stump falls off to prevent moisture retention and infection. Sponge baths are recommended instead.
- Cover the hands with socks or sleeves at all times: While covering hands temporarily can prevent scratches, prolonged covering may interfere with newborn sensory development and exploration.
- Apply mildly scented lotion to face as needed: Newborn skin is sensitive, and scented lotions may cause irritation or allergic reactions. If needed, only fragrance-free moisturizers should be used.
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