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 B

Explanation

Choice A rationale:

Hypertonia (increased muscle tone) is not a manifestation of hypoglycemia in a newborn. Instead, hypotonia (decreased muscle tone) is more characteristic.

Choice B rationale:

This is the correct choice. Jitteriness is a common sign of hypoglycemia in a newborn. It may be accompanied by other symptoms like poor feeding, tremors, and irritability.

Choice C rationale:

Acrocyanosis (bluish discoloration of the hands and feet) is a normal finding in newborns and is not specifically associated with hypoglycemia.

Choice D rationale:

Generalized petechiae (small red or purple spots on the skin caused by bleeding under the skin) are not indicative of hypoglycemia but may be associated with other medical conditions.

A. Vitamin E. B. Vitamin D. C. Fiber. D. Calcium.

Correct Answer is D

Explanation

A. Vitamin E requirements do not significantly increase during pregnancy.
B. While vitamin D is important for calcium absorption, the recommended intake does not increase during pregnancy.
C. Fiber intake is beneficial for digestion but does not have increased requirements specific to pregnancy.
D. Calcium intake should be increased to support fetal bone and teeth development.

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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

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Explanation

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