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.
A. Increased fetal movement: Increased fetal movement is generally not considered a complication after an amniocentesis. Fetal movement is a positive sign, indicating fetal well-being. However, it's important to monitor for any changes in movement patterns.
B. Leakage of fluid from the vagina: Leakage of amniotic fluid from the vagina is a potential complication after amniocentesis. It may indicate rupture of the amniotic sac, which can lead to preterm labor and other complications. This finding should be reported promptly to the healthcare provider.
C. Upper abdominal discomfort: Mild upper abdominal discomfort can occur after an amniocentesis, but it is not typically a severe complication. It may be related to the procedure itself and often resolves with rest. However, persistent or severe discomfort should be reported.
D. Urinary frequency: Urinary frequency is not typically associated with complications after an amniocentesis. It may be a normal symptom related to the position of the uterus or other factors, but it does not generally warrant immediate reporting as a complication.
Correct Answer is B
Explanation
The correct answer is B. Explain to the client this is an expected occurrence.
A. Tell the client to follow up with a dermatologist: While it's always good to encourage clients to seek professional advice if they have concerns, in the context of melasma during pregnancy, it is generally a normal physiological change. A dermatologist may not be needed specifically for this condition unless there are other unusual symptoms.
B. Explain to the client this is an expected occurrence: This is the correct action. It's important for the nurse to reassure the client that blotchy hyperpigmentation on the forehead is a common and expected change during pregnancy. Providing education and support can help alleviate the client's concerns.
C. Instruct the client to increase her intake of vitamin D: Blotchy hyperpigmentation is not typically addressed by increasing vitamin D intake. While adequate nutrition is important during pregnancy, this specific concern is related more to hormonal changes than nutritional deficiencies.
D. Inform the client she might have an allergy to her skin care products: Melasma is primarily related to hormonal changes in pregnancy rather than an allergic reaction to skin care products. While assessing for allergies is essential in certain situations, it may not be the primary concern in this case.
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