A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

Maintain the client in the lithotomy position.

Encourage the client to empty her bladder every 2 hr.

Remind the client to bear down with each contraction.

Perform vaginal examinations frequently,

Answer and Explanation

The Correct Answer is B

A. Maintain the client in the lithotomy position: The lithotomy position is not typically

maintained during the active phase of labor. It is used during the pushing stage (second stage) of labor.
B.   Encourage the client to empty her bladder every 2 hr: A full bladder can impede fetal descent and progress during labor, so encouraging the client to empty her bladder regularly is essential.
C.   Remind the client to bear down with each contraction: Bearing down during the active phase of labor is not appropriate, as it may lead to premature pushing and cervical swelling.
D.   Perform vaginal examinations frequently: Frequent vaginal examinations can increase the risk of infection and should be minimized during labor.

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Correct Answer is C

Explanation

A) Fetal head compression: Fetal head compression would typically result in variable decelerations, not late decelerations.
B) Umbilical cord compression: Umbilical cord compression is associated with variable decelerations, not late decelerations.
C) Uteroplacental insufficiency: Late decelerations occur due to decreased blood flow and oxygen supply to the fetus, which can be caused by uteroplacental insufficiency. This condition can lead to fetal hypoxia during contractions.
D) Maternal bradycardia: Maternal bradycardia would not directly cause late decelerations in the fetal heart rate.

A. Position the client on her side. B. Elevate the client's legs. C. Increase the infusion rate of the IV fluid. D. Administer oxygen via face mask.

Correct Answer is A

Explanation

A. Position the client on her side: Late decelerations are often associated with uteroplacental insufficiency, which may be improved by changing the maternal position to improve blood flow to the placenta.
B. Elevate the client's legs: Elevating the client's legs would not directly address the cause of late decelerations.
C. Increase the infusion rate of the IV fluid: While ensuring adequate hydration is important, it is not the priority action when late decelerations are noted.
D. Administer oxygen via a face mask: Oxygen administration may be necessary, but it is not the priority action. Positioning the client on her side to improve blood flow is the priority.

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A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

Correct Answer is C

Explanation

A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

Correct Answer is A

Explanation

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