A nurse is assisting with the care of a client who is in labour and has an external electronic fetal monitor. The nurse observes that the fetal heart rate begins to decelerate after the contraction has started, with the lowest point of the deceleration occurring after the peak of the contraction. Which of the following actions should the nurse take first?
Increase the rate of the maintenance IV infusion.
Administer oxygen using a nonrebreather mask.
Elevate the client's legs.
Place the client in the lateral position.
The Correct Answer is D
Choice A rationale:
Increasing the rate of the maintenance IV infusion may be a rational action in some situations, but it is not the first priority when dealing with a fetal heart rate deceleration. The priority is to address the deceleration and potential fetal distress promptly.
Choice B rationale:
Administering oxygen using a nonrebreather mask might be beneficial for the client, but it is not the primary action to take when dealing with fetal heart rate deceleration. The priority is to address the deceleration and ensure fetal well-being.
Choice C rationale:
Elevating the client's legs is unlikely to have a significant impact on fetal heart rate deceleration. This action is more relevant in cases of maternal hypotension or when trying to improve venous return to the heart. It is not the first-line intervention for fetal heart rate decelerations.
Choice D rationale:
Placing the client in the lateral (side-lying) position is the correct action to take first. This position can help relieve pressure on the vena cava, improve blood flow, and increase oxygen supply to the fetus. By changing the client's position, the nurse can potentially resolve the fetal heart rate deceleration and improve fetal well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The priority nursing action after an amniotomy is to ensure the well-being of both the mother and the baby. While evaluating the client for signs of infection is important, it is not the immediate priority. Infection can be a concern after any invasive procedure, but checking the fetal heart rate pattern takes precedence to assess the baby's condition immediately after the amniotomy.
Choice B rationale:
Checking the fetal heart rate pattern is the priority because it helps to monitor the baby's well-being and detect any signs of fetal distress. Amniotomy is the artificial rupture of the amniotic membrane, and it can sometimes lead to changes in the baby's heart rate, which may indicate distress or other complications. Identifying and addressing these changes
promptly is crucial for the baby's safety.
Choice C rationale:
Observing the color and consistency of amniotic fluid is essential to assess for any abnormalities or meconium staining, which could indicate fetal distress or potential issues. However, this action should follow the immediate concern of checking the fetal heart rate pattern since fetal distress takes priority over amniotic fluid characteristics.
Choice D rationale:
Taking the client's temperature is important, but it is not the priority immediately after an amniotomy. Monitoring the client's temperature is a routine nursing action to detect any signs of infection. However, the priority in this situation is to ensure the baby's well-being through fetal heart rate assessment.
Correct Answer is A
Explanation
Choice A:
During the immediate postpartum period, shaking chills can be indicative of an infection or fever. Therefore, the nurse should first assess the client's temperature to identify if there is a fever. This information is crucial for making appropriate clinical decisions and providing necessary interventions.
Choice B:
The reason for not selecting B, and placing the client on seizure precautions, is that shaking chills alone do not necessarily indicate a seizure. Seizure precautions are typically implemented for clients with a history of seizures or those at risk for seizures due to neurological conditions. In this scenario, focusing on the client's temperature is more relevant to address the immediate concern.
Choice C:
The reason for not choosing C, notifying the charge nurse, is that this action might not directly address the client's condition. While involving the charge nurse can be essential for certain situations, it is not the primary intervention required for a client experiencing shaking chills. The nurse should first assess the client and initiate appropriate actions based on their assessment.
Choice D:
The reason for not selecting D, covering the client with warm blankets, is that shaking chills are often associated with fever, which indicates the body is trying to raise its temperature. Providing warm blankets may exacerbate the fever and is not the appropriate initial action. Determining the client's temperature is necessary to guide further interventions effectively.
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