A nurse is attending to a client in labor who is showing late decelerations on the electronic fetal monitor.

What should be the nurse’s initial course of action?

Insert an IV catheter.

Assist the client into the left-lateral position.

Apply a fetal scalp electrode.

Perform a vaginal exam.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While inserting an IV catheter can be a part of the overall management plan for a client showing late decelerations on the electronic fetal monitor, it is not the initial course of action. The primary concern with late decelerations is that they may indicate fetal hypoxia, and the first response should be aimed at improving fetal oxygenation.
Choice B rationale
Assisting the client into the left-lateral position is the correct initial response when late decelerations are observed on the electronic fetal monitor. This position helps to maximize blood flow to the uterus and placenta, thereby improving oxygen delivery to the fetus.
Choice C rationale
Applying a fetal scalp electrode may be useful for obtaining a more accurate fetal heart rate tracing, but it is not the initial response to late decelerations. The priority is to address the potential fetal hypoxia that late decelerations may indicate.
Choice D rationale
Performing a vaginal exam would not be the initial response to late decelerations. While a vaginal exam can provide valuable information about the progress of labor, it does not address the issue of potential fetal hypoxia indicated by late decelerations.

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Correct Answer is D

Explanation

Choice A rationale
Postpartum depression is characterized by severe mood swings, crying too much, difficulty bonding with the baby, withdrawing from family and friends, loss of appetite or eating much more than usual, inability to sleep or sleeping too much, overwhelming tiredness or loss of energy. While some of these symptoms overlap with the ones mentioned in the question, postpartum depression is usually more severe and lasts longer.
Choice B rationale
The letting-go phase is the final phase of maternal adjustment during which the mother moves forward from her existing role to take on a new one as a parent. This phase is characterized by reestablishment of relationships with others, resumption of sexual intimacy, resolution of physical symptoms, and attainment of a new normal. The symptoms mentioned in the question do not align with this phase.
Choice C rationale
Postpartum psychosis is a rare but serious mental health illness that can affect a woman soon after she has a baby. Symptoms can include hallucinations, delusions, a manic mood, a low mood, loss of inhibitions, restlessness, and severe confusion. The symptoms mentioned in the question do not align with this condition.
Choice D rationale
This is the correct answer. Postpartum fatigue is characterized by extreme tiredness that doesn’t get better with rest or sleep. This fatigue can make it difficult for the new mother to care for herself and her baby. The symptoms mentioned in the question - tearfulness, insomnia, lack of appetite, and a feeling of letdown - are all common symptoms of postpartum fatigue.

A. Low birth weight B. Appropriate for gestational age C. Large for gestational age D. Small for gestational age

Correct Answer is B

Explanation

Choice A rationale
Low birth weight is defined as a birth weight of less than 2500 grams. This newborn weighs 3200 grams, so it does not fall into this category.
Choice B rationale
A newborn is considered appropriate for gestational age if its weight falls between the 10th and 90th percentile for its gestational age. This newborn’s weight is in the 60th percentile for its gestational age of 38 weeks, so it is appropriate for gestational age.
Choice C rationale
Large for gestational age refers to a newborn whose weight is above the 90th percentile for its gestational age. This newborn’s weight is in the 60th percentile, so it does not fall into this category.
Choice D rationale
Small for gestational age refers to a newborn whose weight is below the 10th percentile for its gestational age. This newborn’s weight is in the 60th percentile, so it does not fall into this category.

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A nurse is attending to a client in labor who is showing late decelerations on the electronic fetal monitor. What should be the nurse’s initial course of action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. The nurse knows these findings are characteristics of:

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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A nurse is attending to a client in labor who is showing late decelerations on the electronic fetal monitor.

What should be the nurse’s initial course of action?