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 C
Explanation
Choice A rationale:
Fentanyl is an opioid analgesic and is not used to counteract the effects of meperidine in the newborn. Both fentanyl and meperidine are opioids, and using fentanyl in this context would not counteract the effects of meperidine.
Choice B rationale:
Flumazenil is a medication used to reverse the effects of benzodiazepines, not opioids like meperidine. It is not appropriate for countering the effects of meperidine in the newborn.
Choice C rationale:
Naloxone is an opioid antagonist that can reverse the effects of opioids like meperidine. When a newborn has been exposed to opioids during labor, such as meperidine given to the mother, there is a risk of respiratory depression in the newborn. Naloxone can quickly reverse this effect and restore normal respiratory function.
Choice D rationale:
Benztropine is an anticholinergic medication used to treat side effects of antipsychotic drugs and is not relevant in this situation. It would not counteract the effects of meperidine on the newborn.
Correct Answer is D
Explanation
Choice A rationale:
This statement is incorrect. The client should receive Rh(D) immune globulin (RhoGAM) if they are Rh-negative and their partner's Rh status is unknown or Rh-positive. This prevents the development of Rh antibodies in the mother's blood, which could be harmful in future pregnancies if the baby is Rh-positive.
Choice B rationale:
This statement is incorrect. Rh(D) immune globulin is administered to an Rh-negative mother within 72 hours after delivery if the baby is Rh-positive. This is done to prevent the mother from developing Rh antibodies that could affect subsequent pregnancies.
Choice C rationale:
This statement is incorrect. There is no restriction on receiving other immunizations after receiving Rh(D) immune globulin. The shot only protects against Rh incompatibility and does not interfere with other immunizations.
Choice D rationale:
This statement is correct. Rh(D) immune globulin can be given after birth to an Rh-negative mother with an Rh-positive baby. This helps protect the mother's future pregnancies from the potential harmful effects of Rh incompatibility.
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