A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse perform?

Prepare equipment needed for newborn resuscitation

Perform endotracheal suctioning as soon as the fetal head is delivered

Prepare the client for an ultrasound examination

Prepare the client for an emergency cesarean birth

Answer and Explanation

The Correct Answer is A

A. Prepare equipment needed for newborn resuscitation.

A. Preparing equipment needed for newborn resuscitation is the correct action.

Meconium-stained amniotic fluid can increase the risk of meconium aspiration syndrome in the newborn. While the fetal heart rate is reassuring, being prepared for potential newborn resuscitation is prudent given the meconium staining.

B. Performing endotracheal suctioning as soon as the fetal head is delivered is not the current standard of care. The American Academy of Pediatrics (AAP) no longer recommends routine suctioning of meconium-stained infants unless they show signs of respiratory distress, poor muscle tone, or a depressed heart rate.

C. Preparing the client for an ultrasound examination is not the immediate priority. Meconium-stained amniotic fluid may be associated with fetal distress, but the focus should be on the current labor and delivery situation.

D. Preparing the client for an emergency cesarean birth is not the first action.

The presence of meconium staining alone does not necessarily indicate the need for an emergency cesarean birth, especially if the fetal heart rate is reassuring.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is D.

A. Maintain the client NPO throughout the procedure: It is not necessary to maintain the client NPO (nothing by mouth) for a nonstress test. The test primarily involves monitoring fetal heart rate in response to the baby's movements and does not require fasting.

B. Place the client in a supine position: Placing the client in a left lateral position is often preferred for NST to optimize uterine blood flow and fetal oxygenation. The supine position can compromise blood flow to the uterus and is generally avoided, especially in later pregnancy.

C. Instruct the client to massage the abdomen to stimulate fetal movement: While the goal of the NST is to monitor fetal movements, instructing the client to actively stimulate fetal movement through abdominal massage is not a standard part of the procedure. Fetal movements should occur naturally.

D. Instruct the client to press the provided button each time fetal movement is detected: This is the correct action. During a nonstress test, the client is typically provided with a button to press whenever she feels fetal movement. This helps correlate fetal movements with changes in the fetal heart rate on the monitor, providing valuable information about the baby's well-being.

A. Administer oxygen at 10 L/min via a nonrebreather mask. B. Change the client's position. C. Apply a fetal scalp electrode D. Increase the rate of the TV infusion

Correct Answer is B

Explanation

A. Administering oxygen at 10 L/min via a nonrebreather mask is an important intervention, but changing the client's position is the priority action when late decelerations are observed. Oxygen administration can follow, but optimizing uteroplacental perfusion through changing position is crucial.

B. Changing the client's position is the correct first action.

Repositioning the client, particularly from a supine to a side-lying position, can help alleviate compression on the vena cava and improve blood flow to the uterus, reducing the likelihood of late decelerations.

C. Applying a fetal scalp electrode is not the initial action when late decelerations are noted. Repositioning the client should be attempted first to address potential issues related to uteroplacental perfusion.

D. Increasing the rate of the intravenous (IV) infusion might not directly address the issue of late decelerations. It's important to focus on maternal positioning first to improve blood flow to the uterus.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

Explanation

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make to the client?

A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

A nurse is reviewing the laboratory report of a newborn who is 24 hr old. Which of the following results should the nurse report to the provider?

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?