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 A

Explanation

Choice A rationale
This is the best response because it acknowledges the client’s question and refers her to a healthcare provider who can provide a comprehensive assessment and discuss the most appropriate contraceptive options for her specific situation.
Choice B rationale
While it’s important to understand a client’s sexual activity when discussing contraception, asking a minor about her sexual activity without a proper context or professional setting may be inappropriate and uncomfortable for the client.
Choice C rationale
This response may come off as judgmental or condescending. It’s crucial to provide a safe and non-judgmental environment when discussing sensitive topics like sexual health and contraception.
Choice D rationale
While barrier methods can be an effective form of contraception, it’s not appropriate to recommend a specific method without a thorough understanding of the client’s health history, lifestyle, and preferences.

A. Baseline BP 140/85, current BP 129/80 B. Baseline BP 110/70, current BP 145/85 C. Baseline BP 120/80, current BP 126/85 D. Baseline BP 110/60, current BP 120/63 .

Correct Answer is B

Explanation

Choice A rationale
A baseline BP of 140/85 mmHg is considered high, but a current BP of 129/80 mmHg is within the normal range. Therefore, this would not typically indicate a risk for pregnancy-induced hypertension.
Choice B rationale
A significant increase in blood pressure from a baseline of 110/70 mmHg to a current BP of 145/85 mmHg could indicate a risk for pregnancy-induced hypertension.
Choice C rationale
A slight increase in blood pressure from a baseline of 120/80 mmHg to a current BP of 126/85 mmHg would not typically indicate a risk for pregnancy-induced hypertension.
Choice D rationale
An increase in blood pressure from a baseline of 110/60 mmHg to a current BP of 120/63 mmHg would not typically indicate a risk for pregnancy-induced hypertension.

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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 leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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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?