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:
Hct (hematocrit) of 34% is a normal finding during pregnancy. Normal ranges vary during pregnancy, but generally, a hematocrit between 33% to 45% is considered normal during the second trimester.
Choice B rationale:
BUN (blood urea nitrogen) of 25 mg/dL should be reported to the provider. BUN measures kidney function, and during pregnancy, values above 20 mg/dL may indicate possible impaired kidney function, which requires further evaluation.
Choice C rationale:
Platelets of 170,000/mm³ are within the normal range during pregnancy. The normal platelet count during pregnancy is typically between 150,000 to 400,000/mm³.
Choice D rationale:
HbA1c (glycated hemoglobin) of 6% is a good indicator of blood sugar control and is within the target range for a pregnant woman with diabetes. The target HbA1c level for pregnant women with diabetes is usually around 6% or lower.
Correct Answer is A
Explanation
The correct answer is choice a. Provide the client with a cool sitz bath.
Choice A rationale:
A cool sitz bath can help reduce swelling and provide pain relief for a client with a fourth-degree laceration of the perineum. Cooling the area can also help minimize inflammation and promote healing.
Choice B rationale:
Methylergonovine is typically used to prevent or treat postpartum hemorrhage by causing uterine contractions. It is not indicated for the management of perineal lacerations.
Choice C rationale:
Applying a moist, warm compress to the perineum is not recommended immediately postpartum for a fourth-degree laceration, as it can increase swelling and discomfort. Cool treatments are preferred initially.
Choice D rationale:
Applying povidone-iodine to the perineum is not a standard practice for managing perineal lacerations. It can cause irritation and is not necessary for wound care in this context.
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