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 ["A","B","C","E"]
Explanation
Choice A rationale: Skin-to-skin contact, also known as kangaroo care, is scientifically supported to stabilize neonatal autonomic functions such as heart rate, respiratory rate, and temperature. It promotes oxytocin release in both the parent and infant, which reduces stress and enhances bonding. For neonates experiencing neonatal abstinence syndrome (NAS), this contact can reduce irritability and improve feeding behaviors by providing a calming sensory input that mimics the intrauterine environment.
Choice B rationale: Decreasing environmental stimuli such as lighting is a key nonpharmacologic intervention for infants with NAS. Bright lights can exacerbate neurologic excitability, leading to increased irritability, tremors, and poor feeding. Dimming the lights helps reduce sensory overload, allowing the infant’s overstimulated nervous system to settle. This intervention supports autonomic regulation and is consistent with evidence-based care for managing withdrawal symptoms in neonates.
Choice C rationale: Singing to the newborn introduces rhythmic auditory stimulation, which has been shown to soothe infants and promote neurobehavioral organization. In NAS, where infants are hypersensitive to stimuli, soft singing can provide a predictable and calming input that may improve feeding coordination and reduce crying. Auditory bonding also supports maternal-infant attachment, which is critical in the context of maternal substance use and psychosocial stressors.
Choice D rationale: Avoiding a pacifier is contraindicated in NAS care. Non-nutritive sucking via pacifiers is a well-established intervention to soothe irritable neonates and improve feeding coordination. It activates the sucking reflex, which has a calming effect on the central nervous system. Denying this comfort measure may increase distress and worsen symptoms such as tremors and high-pitched crying, making this choice scientifically inappropriate.
Choice E rationale: Swaddling with the legs flexed mimics the fetal position and provides proprioceptive input that helps calm the overstimulated nervous system in NAS. This positioning reduces excessive motor activity and supports neuromuscular control. Flexed swaddling also enhances sleep quality and decreases the frequency of tremors and startle responses, which are hallmark symptoms of opioid withdrawal in neonates.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
? Rationale for Correct Answers
Glucose level is the priority because the newborn’s blood glucose is 35 mg/dL, which is below the normal threshold of 40–45 mg/dL. Neonatal hypoglycemia can lead to seizures, apnea, and brain injury if untreated. Immediate intervention is critical to prevent neurologic damage.
Feeding difficulties are the next concern because they contribute to poor caloric intake and perpetuate hypoglycemia. The newborn exhibits poor latch, uncoordinated suck, and loose stools—hallmarks of neonatal abstinence syndrome (NAS), which impair feeding and weight gain.
❌ Rationale for Incorrect Response 1 Options
Respiratory rate (65/min) is mildly elevated but within the upper limit of normal for newborns (30–60/min). No signs of respiratory distress (e.g., nasal flaring, retractions, grunting) are present, making this a lower priority.
Heart rate (165/min) is within the normal neonatal range (120–160/min). Mild tachycardia can be attributed to irritability or crying and is not immediately life-threatening.
Temperature (37.5°C) is within the normal range for newborns (36.5–37.5°C). There is no evidence of fever or hypothermia requiring urgent intervention.
❌ Rationale for Incorrect Response 2 Options
Skin findings such as mottling are nonspecific and often seen in NAS or immature autonomic regulation. They are not immediately dangerous.
Cry characteristics like high-pitched crying are typical of NAS but are not life-threatening and do not require urgent intervention.
Tremors are a common NAS symptom but are not acutely harmful unless associated with seizures, which are not reported here.
? Take-Home Points
- Neonatal hypoglycemia (<40 mg/dL) is a medical emergency requiring prompt correction to prevent neurologic injury.
- Feeding difficulties in NAS exacerbate hypoglycemia and must be addressed to ensure adequate caloric intake.
- NAS presents with autonomic, gastrointestinal, and neurologic symptoms; diagnosis is clinical and supported by maternal and neonatal drug screens.
- NAS must be differentiated from neonatal sepsis, hypoxic-ischemic encephalopathy, and metabolic disorders, which may present similarly.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.