A nurse is assisting in the care of a client in the intrapartum unit.
Which of the following actions should the nurse take? Select all that apply.
Increase the rate of maintenance IV fluid.
Assist the client to a lateral position.
Apply oxygen via nasal cannula at 2L.
Administer misoprostol.
Notify the primary health care provider of fetal heart rate changes.
Correct Answer : A,B,E
Choice A rationale: Increasing the rate of maintenance IV fluids improves maternal intravascular volume and enhances uteroplacental perfusion. Late decelerations are indicative of uteroplacental insufficiency, where fetal oxygenation is compromised during contractions. By increasing fluid volume, the nurse can help optimize cardiac output and improve oxygen delivery to the fetus, potentially reducing the frequency or severity of late decelerations.
Choice B rationale: Assisting the client into a lateral position, preferably left lateral, helps relieve pressure on the inferior vena cava and improves venous return. This position enhances uteroplacental blood flow and oxygen delivery to the fetus. It is a first-line intervention for late decelerations, as it can reduce fetal hypoxia by improving maternal-fetal circulation without requiring pharmacologic measures.
Choice C rationale: Oxygen via nasal cannula at 2 L is insufficient to address fetal distress. When supplemental oxygen is indicated for intrauterine resuscitation, it should be administered via a non-rebreather mask at 10 L/min to maximize maternal oxygenation and fetal oxygen delivery. A nasal cannula at 2 L does not provide the high concentration needed to improve fetal oxygenation during late decelerations.
Choice D rationale: Misoprostol is a prostaglandin used for cervical ripening and labor induction. It is contraindicated in the presence of fetal distress, such as late decelerations, because it can cause uterine hyperstimulation and worsen fetal hypoxia. Administering misoprostol in this context could exacerbate the situation and increase the risk of adverse outcomes for the fetus.
Choice E rationale: Notifying the primary health care provider is essential when late decelerations are observed, as they indicate potential fetal compromise. Timely communication allows for further evaluation and potential interventions, such as adjusting oxytocin, initiating intrauterine resuscitation, or preparing for operative delivery if the fetal status does not improve. This action ensures collaborative and responsive care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Vaginal fluid with a pH of 5.3 is acidic and falls within the normal range for vaginal secretions, which are typically between 3.8 and 4.5. Amniotic fluid is alkaline, with a pH of 7.0 to 7.5. Therefore, an acidic pH does not indicate premature rupture of membranes.
Choice B rationale
Nitrazine paper turning dark blue indicates an alkaline pH, which is characteristic of amniotic fluid (pH 7.0-7.5). The presence of alkaline fluid in the vagina suggests premature rupture of membranes, as normal vaginal secretions are acidic.
Choice C rationale
A positive ferning test, where amniotic fluid dries in a fern-like pattern on a microscope slide, indicates the presence of amniotic fluid. A negative ferning test would suggest that the fluid is not amniotic fluid.
Choice D rationale
Nitrazine paper turning yellow indicates an acidic pH, which is consistent with normal vaginal secretions or urine. This finding would suggest that the fluid is not amniotic fluid, as amniotic fluid is alkaline and would turn the paper blue or dark blue.
Correct Answer is A
Explanation
Choice A rationale
Folic acid, a B vitamin, is crucial for neural tube development, which occurs early in gestation. Adequate intake, typically 400 mcg daily before conception and throughout the first trimester, significantly reduces the risk of neural tube defects like spina bifida and anencephaly by supporting proper cell division and DNA synthesis, thereby ensuring complete closure of the neural tube.
Choice B rationale
Folic acid does not directly prevent bleeding in the newborn. While it is involved in red blood cell formation, its primary role in preventing bleeding is not prominent. Vitamin K is the nutrient primarily associated with blood clotting factors and preventing hemorrhagic disease in newborns.
Choice C rationale
While some B vitamins contribute indirectly to overall cellular health, folic acid is not primarily known for strengthening the newborn's immune system. Other nutrients like Vitamin C, Vitamin D, and zinc are more directly involved in immune function and antibody production to resist infections.
Choice D rationale
Folic acid does not primarily contribute to making a baby's bones strong. Calcium and Vitamin D are the essential nutrients required for proper bone mineralization, growth, and density, ensuring the development of a robust skeletal system in the fetus and newborn.
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