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 D
Explanation
Choice A rationale:
The clinical finding of 0 station does not provide information about the fetal head's position in the left occiput posterior position. Station refers to the level of the presenting part in relation to the ischial spines, not the position.
Choice B rationale:
The clinical finding of 0 station does not indicate that the largest fetal diameter has passed through the pelvic outlet. The station only tells us the level of the presenting part and does not provide information about the diameter passing through the pelvic outlet.
Choice C rationale:
The clinical finding of 0 station does not directly involve the palpability of the posterior fontanel. Station is determined based on the level of the presenting part in the birth canal.
Choice D rationale:
This is the correct interpretation of the clinical finding. 0 station means that the presenting part (usually the baby's head) is at the level of the ischial spines, which serves as a reference point during labor. As labor progresses and the baby moves further down the birth canal, the station becomes more negative (e.g., -1, -2) until delivery occurs.
Correct Answer is C
Explanation
Choice A rationale:
Polyuria is not an adverse effect of epidural anesthesia. It is unrelated to this type of pain control.
Choice B rationale:
Hypertension is not an adverse effect of epidural anesthesia. Epidurals can actually cause a decrease in blood pressure due to vasodilation.
Choice C rationale:
This is the correct choice. Pruritus, or itching, is a common adverse effect of epidural anesthesia caused by the release of histamines from local anesthetics.
Choice D rationale:
Dry mouth is not an adverse effect of epidural anesthesia. Dry mouth is more commonly associated with general anesthesia or medications with anticholinergic effects.
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