A nurse is attending to a client in active labor and observes late decelerations on the fetal monitor.
What should be the nurse’s priority action?

Administer oxygen via face mask.

Increase the rate of the IV fluid infusion.

Elevate the client’s legs.

Position the client on her side.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Administering oxygen via face mask is a common intervention for various complications during labor. However, it is not the priority action when late decelerations are observed on the fetal monitor. Late decelerations are a sign of fetal hypoxia, which is often caused by uteroplacental insufficiency. While oxygen administration can help increase the overall oxygen available, it does not directly address the cause of the late decelerations.
Choice B rationale
Increasing the rate of the IV fluid infusion can help improve maternal circulation and potentially increase placental perfusion. However, this intervention is not the most immediate or effective response to late decelerations.
Choice C rationale
Elevating the client’s legs is not the recommended action in response to late decelerations. This position does not alleviate the cause of late decelerations and can actually impede blood flow to the uterus.
Choice D rationale
Positioning the client on her side, specifically the left side, is the priority action when late decelerations are observed. This position helps to maximize blood flow to the uterus and placenta, thereby improving oxygen delivery to the fetus.

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Correct Answer is D

Explanation

If a patient in labor who has received an epidural anesthesia block has a blood pressure reading of 80/40 mm Hg, the nurse’s immediate course of action should be to position the patient laterally. This helps to maximize venous return and cardiac output, thereby improving maternal blood pressure and fetal perfusion.

A. 0.2 mg B. 0.20 mg C. 20 mg D. 2 mg

Correct Answer is A

Explanation

Choice A rationale
The correct transcription of two tenths of a milligram is 0.2 mg. This format avoids any potential confusion that could lead to a medication error.
Choice B rationale
While 0.20 mg is technically correct, it is not the preferred format. The trailing zero after the decimal point is unnecessary and could potentially lead to confusion.
Choice C rationale
20 mg is not correct. This is 100 times the intended dose of two tenths of a milligram, and could lead to a serious medication error.
Choice D rationale
2 mg is not correct. This is 10 times the intended dose of two tenths of a milligram, and could lead to a medication error.

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A nurse is attending to a client in active labor and observes late decelerations on the fetal monitor. What should be the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is attending to a patient in labor who has received an epidural anesthesia block. The patient’s blood pressure reads 80/40 mm Hg and the fetal heart rate is 140/min. What should be the nurse’s immediate course of action?

Correct Answer is D

Explanation

A nurse is preparing an in-service program about preventing medication errors when transcribing a prescription. The nurse is using a dosage example of two tenths of a milligram. Which of the following examples should the nurse use to show appropriate transcription of this dosage?

Correct Answer is A

Explanation

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following?

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A nurse is attending to a client in active labor and observes late decelerations on the fetal monitor. What should be the nurse’s priority action?

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A nurse is attending to a client in active labor and observes late decelerations on the fetal monitor.
What should be the nurse’s priority action?