A nurse is caring for a client who is experiencing a decrease in the fetal heart rate. Which of the following actions should the nurse take?
Administer oxygen at 10 L/min via a non-rebreather mask.
Apply a fetal scalp electrode.
Change the client’s position.
Increase the rate of the IV infusion.
The Correct Answer is C
Choice A rationale
Administering oxygen at 10 L/min via a non-rebreather mask is a common intervention for fetal distress, but it is not the first action a nurse should take when a decrease in fetal heart rate is observed.
Choice B rationale
Applying a fetal scalp electrode can provide a more accurate fetal heart rate reading, but it is an invasive procedure and is not the first action a nurse should take when a decrease in fetal heart rate is observed.
Choice C rationale
Changing the client’s position is the correct action. This is often the first intervention for a decrease in fetal heart rate because it can relieve possible compression of the umbilical cord, which can improve fetal circulation and increase the fetal heart rate.
Choice D rationale
Increasing the rate of the IV infusion can increase maternal blood volume and improve placental blood flow, but it is not the first action a nurse should take when a decrease in fetal heart rate is observed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
If the fundus is palpable to the right of the midline, it may indicate that the bladder is distended. A full bladder can displace the uterus to one side.
Choice B rationale
Frequent uterine contractions are not typically associated with bladder distention. These contractions are a normal part of the postpartum period as the uterus returns to its pre- pregnancy size.
Choice C rationale
Having less than 2.5 cm of rubra lochia on a perineal pad does not indicate bladder distention. This is a normal finding in the postpartum period.
Choice D rationale
An increased thirst is not typically associated with bladder distention. It is a common symptom in the postpartum period due to fluid shifts and breastfeeding.
Correct Answer is D
Explanation
Choice A rationale
While changes in an infant’s sleep patterns can be a sign of many issues, they are not a specific indicator of a food allergy.
Choice B rationale
Rice cereals are typically one of the first foods introduced to infants and are usually well- tolerated. They are not known to cause problems during lactation.
Choice C rationale
The foods a mother eats can affect breast milk, but they do not typically cause food allergies. Most babies can tolerate a variety of foods in a mother’s diet without any problems.
Choice D rationale
If there is a strong family history of peanut allergies, the mother might want to avoid eating peanuts while breastfeeding. However, current research suggests that early exposure to potential allergens may actually decrease the risk of developing allergies.
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