A nurse is caring for a client who is in active labor and notes late decelerations in the FHR on the external fetal monitor. Which of the following actions should the nurse take first?

Change the client's position.

Palpate the uterus to assess for tachysystole.

Increase the client's IV infusion rate.

Administer oxygen at 10 L/min via a nonrebreather mask.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

When late decelerations are noted in the fetal heart rate (FHR) tracing, it indicates that the fetal oxygen supply may be compromised. The nurse should first change the client's position, such as moving her to the left lateral position or a hands-and-knees position, to improve uteroplacental blood flow and relieve pressure on the vena cava.

Choice B rationale:

Palpating the uterus to assess for tachysystole is not the priority action when late decelerations are observed. Tachysystole refers to excessively frequent uterine contractions and may contribute to fetal distress, but the immediate concern is addressing the decelerations.

Choice C rationale:

Increasing the client's IV infusion rate may not address the underlying cause of late decelerations. While maintaining hydration is important, it's not the first action to take in this situation.

Choice D rationale:

Administering oxygen at 10 L/min via a non-rebreather mask may be beneficial for the client and fetus, but it is not the first action to take. The nurse should address the position change first to improve oxygenation through better blood flow before considering supplemental oxygen.

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Correct Answer is C

Explanation

Choice A rationale:

Keeping the newborn dressed while receiving phototherapy is not recommended because the baby's skin needs to be exposed to the light to effectively treat hyperbilirubinemia. Direct exposure to light helps break down the excess bilirubin in the baby's blood, leading to its excretion.

Choice B rationale:

Applying lotion to the skin twice daily is contraindicated during phototherapy. Lotions and creams can block the light from reaching the skin and hinder the therapeutic effects of the phototherapy. The baby's skin should remain exposed to the light for optimal treatment.

Choice C rationale:

Maintaining an eye mask over the newborn's eyes is essential during phototherapy. The eyes are sensitive to light, and prolonged exposure to the phototherapy light can lead to eye damage. Using an eye mask protects the baby's eyes while allowing the rest of the body to receive the necessary light treatment.

Choice D rationale:

Maintaining the phototherapy during blood draws is crucial to ensure continuous treatment of hyperbilirubinemia. Interrupting the phototherapy during blood draws might result in the rebound of bilirubin levels, which can be harmful to the baby.

A. BUN 35 mg/dL. B. Hgb 15 mg/dL. C. Bilirubin 0.6 mg/dL. D. Hct 37%.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should report a blood urea nitrogen (BUN) level of 35 mg/dL to the provider. BUN measures the amount of nitrogen in the blood and is used to assess kidney function. An elevated BUN can indicate impaired renal function, which is a concern in preeclampsia, as it may signify reduced blood flow to the kidneys.

Choice B rationale:

Hemoglobin (Hgb) level of 15 mg/dL is within the normal range for pregnancy (normal range: 11-15 g/dL), so there is no need to report it to the provider.

Choice C rationale:

Bilirubin level of 0.6 mg/dL is within the normal range (normal range: 0.2-1.3 mg/dL), so there is no need to report it to the provider.

Choice D rationale:

Hematocrit (Hct) level of 37% is within the normal range for pregnancy (normal range: 33- 45%), so there is no need to report it to the provider.

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A nurse is caring for a client who is in active labor and notes late decelerations in the FHR on the external fetal monitor. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?

Correct Answer is C

Explanation

A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?

Correct Answer is A

Explanation

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