A nurse is caring for a client who is in active labor and notes persistent late decelerations on the fetal monitor.Which of the following are the priority nursing actions? (Select all that apply.)
Document the findings in the client's medical record.
Notify the healthcare provider immediately.
Administer a tocolytic medication to stop contractions.
Reposition the client to a side-lying position.
Administer pain medication to the client.
Administer oxygen to the client.
Correct Answer : B,D,F
Choice A rationale
Documenting the findings in the client's medical record is important but is not the priority action when persistent late decelerations are noted. Immediate interventions are needed to improve fetal oxygenation.
Choice B rationale
Notifying the healthcare provider immediately is crucial as persistent late decelerations indicate fetal distress. The provider can decide on further interventions to ensure the safety of the mother and fetus.
Choice C rationale
Administering a tocolytic medication to stop contractions is not appropriate in this scenario. The priority is to improve fetal oxygenation, not to stop contractions.
Choice D rationale
Repositioning the client to a side-lying position can help improve blood flow to the uterus and placenta, enhancing fetal oxygenation. This is a priority intervention.
Choice E rationale
Administering pain medication to the client is not a priority in this situation. The focus should be on addressing fetal distress and improving oxygenation.
Choice F rationale
Administering oxygen to the client increases the oxygen available to the fetus and is a priority intervention when persistent late decelerations are noted.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Rationale for correct condition: The client is likely experiencing PPROM, as evidenced by the sudden gush of clear fluid and continued light leakage, confirmed by fluid pooling in the vaginal vault that tested positive for ferning. PPROM can lead to preterm labor and increased risk of infection. The absence of contractions or bleeding, and the mild lower abdominal discomfort, further supports this diagnosis.
Rationale for actions: Administering prophylactic antibiotics helps prevent infection, which is a significant risk with PPROM. Educating the client on kick counts ensures monitoring of fetal well-being. Preparing for an emergent C-section is not immediately necessary as the cervix is closed. Providing IV fluids for hypotension is not applicable here as blood pressure is elevated. Discharging the client with follow-up in one week is inappropriate given the risk of infection and preterm labor.
Rationale for parameters: Monitoring signs of infection is crucial, as PPROM increases infection risk. Maternal blood pressure trends must be watched due to elevated readings, suggesting possible complications. Meconium-stained amniotic fluid, while concerning, is not present. Maternal platelet levels and fundal height measurements do not directly address the current risks associated with PPROM.
Rationale for incorrect conditions: Placental abruption typically involves abdominal pain and bleeding, which are absent. Preeclampsia involves hypertension and proteinuria, but no significant proteinuria is present. Oligohydramnios involves decreased amniotic fluid, but the client reports clear fluid leakage indicating rupture of membranes.
Correct Answer is A
Explanation
Choice A rationale
Dyspnea, or difficulty breathing, is a serious adverse effect of terbutaline that should be reported to the provider. Terbutaline can cause bronchospasm and pulmonary edema, leading to respiratory distress.
Choice B rationale
Headaches are a common side effect of terbutaline but are not considered a serious adverse effect that requires immediate reporting to the provider.
Choice C rationale
Nervousness is a common side effect of terbutaline and is usually mild. It does not require immediate reporting to the provider unless it becomes severe.
Choice D rationale
Tremors are a common side effect of terbutaline and are usually mild. They do not require immediate reporting to the provider unless they become severe.
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