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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A rationale:
This would be incorrect advice. Increasing dietary fiber is commonly recommended during pregnancy to prevent constipation, but it does not address stress incontinence.
Choice B rationale:
This is a correct choice. Kegel exercises are beneficial during pregnancy to strengthen the pelvic floor muscles, which can help manage stress incontinence.
Choice C rationale:
This would be incorrect advice. Restricting daily fluid intake during pregnancy is generally not recommended as it can lead to dehydration and is unlikely to improve stress incontinence.
Choice D rationale:
This is another correct choice. Caffeine is a bladder irritant and can worsen stress incontinence, so reducing caffeine intake can be helpful.
Choice E rationale:
This would be incorrect advice. Regular exercise during pregnancy is generally encouraged unless there are specific medical reasons to avoid it. Avoiding daily exercise is not the appropriate approach to manage stress incontinence.
Correct Answer is D
Explanation
Choice A rationale:
A client who gave birth 1 day ago and needs Rh(D) immune globulin should be seen soon but not necessarily first. Rh(D) immune globulin is administered to Rh-negative mothers with Rh- positive infants to prevent isoimmunization in future pregnancies.
Choice B rationale:
A client who gave birth 3 days ago and reports breast fullness is likely experiencing normal postpartum breast engorgement. This client can be attended to after the client with more urgent symptoms.
Choice C rationale:
A client who gave birth 12 hours ago and reports an increase in urinary output might have diuresis, which is a common postpartum physiological change. Although this requires assessment, it is not as urgent as the client in choice D.
Choice D rationale:
The nurse should see the client who gave birth 8 hours ago and is saturating a perineal pad every hour first because excessive postpartum bleeding could indicate hemorrhage, a potentially life-threatening complication. Immediate assessment and intervention are crucial in this situation.
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