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 A
Explanation
Choice A rationale:
When a newborn is receiving phototherapy for hyperbilirubinemia, it is essential to avoid using lotions or ointments on the skin. Phototherapy works by breaking down bilirubin in the skin, and any barriers like lotions or ointments can interfere with this process. The baby's skin needs to be exposed to the light to effectively reduce bilirubin levels.
Choice B rationale:
Dressing the newborn in lightweight clothing is a correct action during phototherapy. The baby should be undressed and placed under the phototherapy lights, with only a diaper on to maximize skin exposure to the light.
Choice C rationale:
Keeping the newborn supine throughout treatment is not a recommended action during phototherapy. To optimize skin exposure to the light, the baby should be placed in a prone position, with the back exposed to the light source.
Choice D rationale:
Measuring the newborn's temperature every 6 hours is essential, but it is not directly related to phototherapy. Temperature monitoring is a routine part of newborn care to assess for signs of infection or other health issues.
Correct Answer is A
Explanation
Choice A rationale:
This manifestation, urine output of 20 mL/hr, is an adverse reaction to magnesium sulfate administration. Magnesium sulfate can lead to decreased urine output, and it is essential for the nurse to monitor the client's urinary output closely. Low urine output may indicate decreased kidney function, which can be a sign of magnesium toxicity.
Choice B rationale:
Hypertension is expected in a client with preeclampsia, and magnesium sulfate is used to help manage and prevent seizures in these cases. While it is essential to monitor and manage hypertension during pregnancy, it is not considered an adverse reaction to magnesium sulfate.
Choice C rationale:
Hyperglycemia is not a common adverse reaction to magnesium sulfate. Magnesium sulfate may cause central nervous system depression, muscle weakness, and respiratory depression, but it does not typically cause hyperglycemia.
Choice D rationale:
A respiratory rate of 16/min is within the normal range for an adult and is not indicative of an adverse reaction to magnesium sulfate. Magnesium sulfate can cause respiratory depression at higher doses, but a respiratory rate of 16/min does not raise immediate concerns.
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