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 B
Explanation
Choice A rationale
2 cm dilated, 60% effaced, 2 cm below the ischial spines is incorrect because the -2 station means the presenting part is above the ischial spines, not below.
Choice B rationale
2 cm dilated, 60% effaced, 2 cm above the ischial spines correctly interprets the given data: cervical dilation, effacement, and station relative to the ischial spines.
Choice C rationale
2 cm effaced, 60% dilated, 2 cm below the ischial spines is incorrect because it reverses effacement and dilation figures and incorrectly places the station.
Choice D rationale
2 cm effaced, 60% dilated, 2 cm above the ischial spines is incorrect due to reversed effacement and dilation figures, though the station is correctly above the ischial spines.
Correct Answer is B
Explanation
Choice A rationale
A magnesium sulfate level of 61 mEq/L is high and may cause toxicity, but the most critical level is higher.
Choice B rationale
A magnesium sulfate level of 70 mEq/L is extremely high and most likely to result in toxicity, including respiratory and cardiac complications.
Choice C rationale
A magnesium sulfate level of 29 mEq/L is elevated but not necessarily indicative of toxicity.
Choice D rationale
A magnesium sulfate level of 45 mEq/L is also high but less critical compared to 70 mEq/L.
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