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","D"]
Explanation
Choice A rationale
Nonsteroidal anti-inflammatory drugs (NSAIDs) primarily exert their therapeutic effects through the inhibition of cyclooxygenase (COX) enzymes, thereby reducing prostaglandin synthesis. While they possess analgesic and anti-inflammatory properties that can alleviate pain and swelling associated with thrombophlebitis, NSAIDs do not directly prevent the formation of thrombi or address the underlying coagulopathy. Therefore, their administration is not a primary prophylactic measure against thrombophlebitis development.
Choice B rationale
Early and frequent ambulation promotes venous return by stimulating the calf muscle pump, which compresses deep veins and propels blood back towards the heart. This mechanical action counteracts venous stasis, a major component of Virchow's triad for thrombus formation. By maintaining blood flow velocity and preventing pooling in the lower extremities, ambulation significantly reduces the risk of deep vein thrombosis and subsequent thrombophlebitis.
Choice C rationale
Applying warm, moist packs to the lower legs can provide symptomatic relief by promoting vasodilation and improving local circulation, which may reduce pain and inflammation associated with existing thrombophlebitis. However, this intervention does not prevent the initial formation of a thrombus. In fact, vasodilation could theoretically increase blood flow to an area with an active clot, but it does not address the fundamental mechanisms of thrombogenesis, such as stasis or hypercoagulability.
Choice D rationale
Elastic stockings apply external graduated compression to the lower extremities, with the highest pressure at the ankle and gradually decreasing pressure proximally. This external pressure helps to reduce venous distention, increase venous blood flow velocity, and prevent the pooling of blood in the superficial and deep veins. By mitigating venous stasis, a critical factor in the pathogenesis of thrombophlebitis, elastic stockings effectively reduce the risk of thrombus formation.
Correct Answer is A
Explanation
Choice A rationale
The newborn's fingers curling around the nurse's finger when placed in the palm describes the grasping reflex, also known as the palmar grasp. This is an expected neurological finding in a full-term newborn, indicating intact primitive reflexes and proper neurological development. This reflex typically persists until about 5-6 months of age.
Choice B rationale
The newborn closing their eyes and keeping them closed when tapped on the forehead is not a typical expected reflex. This describes the glabellar reflex, which involves blinking in response to tapping between the eyebrows. However, sustained eye closure without blinking is not a characteristic normal finding, suggesting potential neurological variation.
Choice C rationale
The newborn turning their head away from the stimulus when their cheek is touched is an unexpected finding. The rooting reflex, a normal primitive reflex, involves the newborn turning their head *towards* the stimulus and opening their mouth when the cheek or corner of the mouth is touched. Turning away would suggest an absent or atypical reflex response.
Choice D rationale
The newborn's legs flexing at the knees and hips when pressure is applied to the soles of the newborn's feet is known as the stepping or walking reflex. This reflex involves coordinated leg movements resembling walking. However, the description here is vague; the plantar grasp reflex involves toe curling, and strong, isolated flexion is not typically the sole response.
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