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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale
While it is important to monitor a client’s temperature regularly, especially if they have a fever, simply checking the client’s temperature in 4 hours is not an adequate response to a temperature of 38.9°C (102°F) in a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. This could indicate an infection, which could be dangerous for both the mother and the baby.
Choice B rationale
Administering glucocorticoids intramuscularly is not typically the first-line treatment for a fever in a pregnant woman. Glucocorticoids are often used to accelerate fetal lung maturity in preterm labor, but they are not typically used to treat infections or fevers.

Choice C rationale
Preparing the client for an emergency cesarean section may be necessary if the client’s condition worsens or if there are other complications, but it is not the immediate response to a fever. The first step would be to identify and treat the cause of the fever, which could be an infection.
Choice D rationale
Administering acetaminophen orally is an appropriate nursing action for a client with a fever. Acetaminophen can help to reduce the client’s fever and make her more comfortable. However, it is also important to identify and treat the underlying cause of the fever, which could be an infection.

A. Massage the client’s fundus. B. Assess the bladder for distention. C. Assess the client’s blood pressure. D. Prepare to administer a prescribed oxytocic preparation.

Correct Answer is A

Explanation

The nurse should first assess the fundus of the uterus. If the uterus is not firm (boggy), it may not be contracting well enough to compress the blood vessels and stop the bleeding. The nurse should massage the fundus until it is firm.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client’s oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?

Correct Answer is D

Explanation

A nurse is caring for a client who is 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 minutes.What should be the nurse’s first action?

Correct Answer is A

Explanation

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