A nurse is caring for a client who is in active labor and is receiving oxytocin via IV infusion. The nurse has applied an internal fetal heart monitor and recognizes an early deceleration of the fetal heart rate tracing. Which of the following actions should the nurse take?
Continue to monitor the client.
Discontinue the oxytocin.
Assist the client to lay on her right side.
Administer oxygen at 8 L/min per mask.
The Correct Answer is A
The correct answer is choice A. Continue to monitor the client.
Choice A rationale:
Early decelerations are typically benign and are caused by fetal head compression during contractions. They usually do not require any specific intervention other than continued monitoring to ensure they remain early decelerations and do not progress to more concerning patterns.
Choice B rationale:
Discontinuing oxytocin is not necessary for early decelerations, as they are not indicative of fetal distress. Oxytocin would be discontinued if there were signs of more severe decelerations or other complications.
Choice C rationale:
Assisting the client to lay on her right side is not specifically required for early decelerations. This position change is more commonly used for variable or late decelerations to improve uteroplacental blood flow.
Choice D rationale:
Administering oxygen at 8 L/min per mask is not needed for early decelerations. Oxygen is typically reserved for situations where there is evidence of fetal hypoxia or distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice **b. Hearing loss**.
Choice A rationale:
Cataracts are not a common finding in newborns with congenital CMV infection. Cataracts are more commonly associated with other congenital infections like rubella, toxoplasmosis, and herpes simplex virus (HSV).
Choice B rationale:
Hearing loss is one of the most common manifestations of congenital CMV infection. Up to 40-58% of infants with symptomatic congenital CMV infection develop sensorineural hearing loss, which can be unilateral or bilateral, and progressive over time.
Choice C rationale:
Macrosomia, or large birth size, is not a typical finding in congenital CMV infection. In fact, infants with symptomatic congenital CMV infection are more likely to be small for gestational age or have intrauterine growth restriction.
Choice D rationale:
Urinary tract infection (UTI) is not a common presentation of congenital CMV infection. CMV can cause inclusion bodies in the urine, but overt UTI is not a typical finding. More common manifestations include petechiae, hepatosplenomegaly, jaundice, and central nervous system involvement.
Correct Answer is A
Explanation
Choice A rationale:
Vibroacoustic stimulation is an appropriate action to perform during a nonstress test if there are no fetal heart rate accelerations. It involves using sound or vibration to stimulate the fetus, potentially eliciting the desired heart rate accelerations.
Choice B rationale:
Placing the client in the Trendelenburg position is not indicated in this situation. It may not benefit the fetus and is not a standard intervention for nonreactive nonstress test results.
Choice C rationale:
Conducting a vaginal exam is not relevant to the situation described in the question. A nonreactive nonstress test does not require a vaginal exam.
Choice D rationale:
Collecting a specimen for an indirect Coombs test is not necessary for this scenario. The test result would not provide information relevant to the nonreactive nonstress test.
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