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A nurse is caring for a client who is 42 weeks of gestation. Based on the assessment findings, which of the following actions should the nurse plan to take? (Select all that apply.)

Increase the oxytocin infusion to 13 mu/min.

Initiate a bolus of primary IV fluids.

Place the client in a sidelying position.

Apply oxygen at 10 L/min via a venturi mask.

Perform a sterile vaginal examination (SVE).

Answer and Explanation

Correct Answer : B,C,E

The correct answer is B, C, and D.

Choice A: Increase the oxytocin infusion to 13 mu/min

Increasing the oxytocin infusion is not indicated in this scenario. Oxytocin is used to induce or augment labor, but if the fetal heart rate tracing is abnormal (Category 3), increasing oxytocin could exacerbate fetal distress. The priority is to stabilize the fetal condition before considering increasing oxytocin.

Choice B: Initiate a bolus of primary IV fluids

Initiating a bolus of primary IV fluids is appropriate. This action helps improve placental perfusion and maternal hydration, which can be beneficial in response to abnormal fetal heart rate tracings. Adequate hydration can enhance uteroplacental blood flow and improve fetal oxygenation.

Choice C: Place the client in a sidelying position

Placing the client in a sidelying position is recommended. This position can improve uteroplacental perfusion and fetal oxygenation, especially if there are signs of fetal distress. It helps to alleviate pressure on the inferior vena cava, enhancing blood flow to the placenta.

Choice D: Apply oxygen at 10 L/min via a venturi mask

While oxygen may be indicated for fetal distress, the correct method is usually a non-rebreather mask at 10 L/min, not a venturi mask. A venturi mask delivers more precise oxygen concentrations but not high-flow oxygen, which is needed in this scenario.

Choice E: Perform a sterile vaginal examination (SVE)

A vaginal exam assesses labor progression, cervical dilation, station, and fetal position. This is important for determining whether labor is progressing appropriately or whether further interventions are needed.

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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.

A. Turn the client onto her side. B. Increase the client's IV fluid infusion rate. C. Administer oxygen to the client. D. Palpate the client's uterus.

Correct Answer is A

Explanation

Choice A:The priority action when the fetal monitor tracing shows late decelerations after the client's membranes rupture is to turn the client onto her side. This position change helps relieve pressure on the vena cava and improves blood flow to the fetus.
Choice B: Increasing the client's IV fluid infusion rate is not the first priority in this situation, as late decelerations are primarily related to uteroplacental insufficiency rather than maternal hydration status.
Choice C: Administering oxygen to the client is important, but turning the client onto her side should be the first action to improve fetal oxygenation.
Choice D: Palpating the client's uterus is not the first priority in the presence of late

decelerations. The focus should be on relieving the compression on the vena cava and improving fetal oxygenation by changing the client's position.

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A nurse is caring for a client who is 42 weeks of gestation. Based on the assessment findings, which of the following actions should the nurse plan to take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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