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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. Place the client in the lateral position.
A. Increasing the rate of maintenance IV infusion may be necessary, but the initial action should be to address potential aortocaval compression. Repositioning the client to the lateral position helps alleviate compression on the vena cava and improves blood flow to the uterus.
B. Placing the client in the lateral position is the correct first action. Changing the client's position, particularly from a supine to a side-lying position, can relieve aortocaval compression and improve uteroplacental perfusion.
C. Elevating the client's legs is not the priority in this situation. Repositioning the client to the lateral position is more important to address potential aortocaval compression.
D. Administering oxygen using a nonrebreather mask may be indicated, but repositioning the client to the lateral position is the first action to address potential aortocaval compression. Oxygen administration can follow if necessary.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}
Explanation
Increase the oxytocin infusion to 13 mu/min:
Anticipated: This action is anticipated. The nurse may consider adjusting the oxytocin infusion rate based on the progress of labor and the response to the current infusion rate.
Place client in a side-lying position:
Anticipated: Placing the client in a side-lying position is an anticipated action. This position can enhance fetal oxygenation and blood flow, especially if there are concerns about fetal well-being.
Initiate bolus of primary IV fluids:
Anticipated: Initiating a bolus of primary IV fluids is an anticipated action. Adequate hydration is important during labor, and a bolus may be initiated if there are signs of dehydration or as part of the overall management plan.
Apply oxygen at 10 L/min via a venturi mask:
Anticipated: Applying oxygen at 10 L/min via a venturi mask is an anticipated action. Oxygen may be administered to the mother to improve oxygenation and, consequently, fetal oxygenation.
Perform sterile vaginal examination (SVE):
Nonessential: Based on the information provided, there is no indication for a sterile vaginal examination at this time. The cervical assessment was performed earlier at 0600, and frequent unnecessary SVEs can increase the risk of infection.
Assign a Bishop score:
Nonessential: Assigning a Bishop score is not essential at this point. The client's cervical status was assessed earlier at 0600, and the current focus is on monitoring the progress of labor with oxytocin.
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