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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While fat-soluble vitamins are essential for overall health, they do not specifically prevent iron deficiency anemia. Iron deficiency anemia occurs when the body doesn’t have enough iron to produce hemoglobin, the part of red blood cells that gives them their red color and enables them to carry oxygen in the blood.
Choice B rationale
Limiting intake of high-protein foods is not a recommended method for preventing iron deficiency anemia. In fact, many high-protein foods, such as meat and eggs, are good sources of iron.
Choice C rationale
While fluoridated water can help prevent tooth decay, it does not prevent iron deficiency anemia. Iron deficiency anemia is prevented by consuming adequate amounts of iron, either from food sources or from supplements.
Choice D rationale
A diet that consists primarily of milk, particularly cow’s milk, can contribute to iron deficiency anemia. Cow’s milk is low in iron and can also decrease absorption of iron and irritate the lining of the intestine, causing small amounts of bleeding and the gradual loss of iron in the stool (poop)4.
Correct Answer is B
Explanation
Choice A rationale
Constipation is not typically associated with a sickle cell crisis. While it can occur due to dehydration, which can trigger a sickle cell crisis, it is not a primary symptom.
Choice B rationale
Pain is the most common symptom of a sickle cell crisis. When sickle-shaped cells block blood flow in the small blood vessels, it can cause severe pain. This pain can occur anywhere in the body, but it most often occurs in the chest, arms, and legs.
Choice C rationale
Bradycardia is not typically a symptom of a sickle cell crisis. Sickle cell crisis primarily affects the blood vessels and does not directly cause a slow heart rate.
Choice D rationale
While a high fever can occur in individuals with sickle cell disease, especially if there is an underlying infection, it is not a primary symptom of a sickle cell crisis.
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