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
Choice A rationale:
The nurse should not measure the abdominal circumference at the level of the newborn's umbilicus every 12 hr because this action does not address the specific problem presented in the scenario, which is abdominal distention and bloody stools. Measuring abdominal circumference is typically done to assess for growth and may not provide valuable information in this situation.
Choice B rationale:
Inserting an orogastric decompression tube with low wall suction is the appropriate action for a newborn with abdominal distension and bloody stools. This intervention can help decompress the gastrointestinal tract, reducing abdominal distention, and possibly preventing further complications.
Choice C rationale:
Providing the newborn with an iron-rich formula containing vitamin B12 every 2 hr is not indicated based on the information provided in the scenario. The newborn's symptoms are suggestive of gastrointestinal issues, and this intervention may not address the underlying cause.
Choice D rationale:
Administering nitric oxide inhalation therapy to the newborn is not appropriate in this context. Nitric oxide inhalation therapy is typically used for conditions like persistent pulmonary hypertension in the newborn, and there is no indication for its use in this case.
Correct Answer is D
Explanation
The correct answer is choice d. “The nurse should measure the newborn’s muscle tone when assigning an Apgar score.”
Choice A rationale:
The Apgar score is determined at 1 and 5 minutes after birth, not at 2 and 7 minutes.
Choice B rationale:
An Apgar score of 8 indicates that the newborn is in good health, not severe distress. Scores of 7-10 are considered normal.
Choice C rationale:
Resuscitation efforts should not be delayed until the first Apgar score is obtained. Immediate resuscitation is initiated if needed, regardless of the Apgar score.
Choice D rationale:
Muscle tone is one of the five criteria assessed in the Apgar score, along with appearance, pulse, grimace, and respiration.
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