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 C
Explanation
Choice A rationale
While it’s true that any internal examination carries a risk of introducing infection, this is not the primary reason to avoid an internal examination in a client with placenta previa.
Choice B rationale
Initiating preterm labor is a concern with any internal examination, but it’s not the primary reason to avoid an internal examination in a client with placenta previa.
Choice C rationale
This is the correct answer. In a client with placenta previa, an internal examination could disturb the placenta and cause severe, potentially life-threatening bleeding.
Choice D rationale
While rupture of the membranes is a risk associated with internal examinations, it’s not the primary reason to avoid an internal examination in a client with placenta previa.
Correct Answer is C
Explanation
Choice A rationale
While accidental lacerations can occur during a cesarean delivery, they are not typically the primary concern immediately after delivery.
Choice B rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a priority concern immediately after delivery.
Choice C rationale
Respiratory distress is a priority concern in a newborn after a cesarean delivery. Newborns delivered by cesarean may have transient tachypnea of the newborn (TTN), a condition characterized by rapid breathing during the first few hours of life.
Choice D rationale
While hypothermia is a concern in newborns, it is not typically the immediate priority following a cesarean delivery.
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