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
Explanation
Choice A rationale:
High calcium levels are not typically associated with the use of anastrozole, an aromatase inhibitor. Aromatase inhibitors work by blocking the conversion of androgens to estrogens, and they do not directly impact calcium levels.
Choice B rationale:
Muscle and joint pain is a common side effect of aromatase inhibitors like anastrozole. These medications can lead to musculoskeletal discomfort, including joint stiffness and pain, which the nurse should inform the client about to ensure she is aware of potential adverse effects.
Choice C rationale:
Heart failure is not a known side effect of anastrozole. The drug's primary concern is its impact on the musculoskeletal system, particularly causing joint and muscle pain.
Choice D rationale:
Polyphagia, which refers to excessive hunger and increased food intake, is not associated with the use of anastrozole. This choice is unrelated to the side effects of the medication and can be ruled out.
Correct Answer is ["A","E"]
Explanation
Choice A rationale:
Nulliparity (never having given birth) is a known risk factor for ovarian cancer. Women who have never had children have a higher risk compared to those who have. This is believed to be associated with the number of ovulatory cycles a woman experiences throughout her lifetime.
Choice B rationale:
History of breastfeeding does not have a direct link to ovarian cancer risk. In fact, breastfeeding is associated with a reduced risk of both breast and ovarian cancer due to hormonal changes that occur during lactation.
Choice C rationale:
Previous use of oral contraceptives is associated with a decreased risk of ovarian cancer. Women who have used birth control pills have a lower risk compared to those who have never used them. The protective effect is believed to be due to the suppression of ovulation.
Choice D rationale:
History of breast cancer is not a risk factor for ovarian cancer. Although both cancers are related to the reproductive system, they have distinct risk factors and characteristics.
Choice E rationale:
Hormone replacement therapy (HRT) is a potential risk factor for ovarian cancer, especially long-term use. The hormones used in HRT can affect hormone levels and may increase the risk of ovarian cancer.
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