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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Maternal bradycardia refers to a slower than normal heart rate in the mother. While it can affect the baby’s health, it doesn’t cause late decelerations on the fetal monitor.
Choice B rationale
Late decelerations are caused by uteroplacental insufficiency, which is a decrease in the blood flow to the placenta that reduces the amount of oxygen and nutrients transferred to the fetus. This is why the nurse would interpret late decelerations as indicating uteroplacental insufficiency.
Choice C rationale
Umbilical cord compression can cause variable decelerations, not late decelerations. Variable decelerations are abrupt decreases in the fetal heart rate, typically associated with contractions, and they vary in onset, depth, and duration.
Choice D rationale
Fetal head compression typically causes early decelerations, not late decelerations. Early decelerations are a mirror image of the contraction and are generally not a concern.
Correct Answer is A
Explanation
Choice A rationale
The statement “I only need to catheterize myself twice every day” should alert the nurse to the need for further education. Individuals with spina bifida who are paralyzed from the waist down often need to perform clean intermittent catheterization (CIC) every 3-4 hours to empty the bladder and prevent urinary tract infections.
Choice B rationale
Using a suppository every night to have a bowel movement is a common practice among individuals with spina bifida. Due to the paralysis, they often have difficulty with bowel movements and may use suppositories or other methods to stimulate bowel movements.
Choice C rationale
Doing wheelchair exercises while watching TV is a good practice for individuals with spina bifida. Regular physical activity can help improve strength, flexibility, and overall health.
Choice D rationale
Carrying a water bottle and drinking a lot of water is a good practice for individuals with spina bifida. Adequate hydration can help prevent urinary tract infections and kidney stones, which are common complications in individuals who perform CIC78910.
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