A nurse is caring for a client who is in active labor.
The nurse notes late decelerations in the fetal heart rate on the monitor tracing. Which of the following actions should the nurse take first?
Initiate internal fetal heart rate monitoring.
Assist the client to a left lateral position.
Palpate the client's uterus for tachysystole.
Increase the infusion rate of the maintenance IV fluid.
The Correct Answer is B
Choice A rationale
Initiating internal fetal heart rate monitoring is an invasive procedure that is not the priority for a non-reassuring fetal heart rate pattern like late decelerations, which often indicate uteroplacental insufficiency. The first step involves non-invasive intrauterine resuscitation measures to immediately improve fetal oxygenation before considering invasive monitoring, unless the external tracing is inadequate.
Choice B rationale
Late decelerations are an indication of uteroplacental insufficiency (decreased blood flow/oxygen to the fetus during the contraction). Assisting the client to a left lateral position is the priority nursing action because it relieves pressure from the gravid uterus on the vena cava, which in turn maximizes venous return to the heart and increases blood flow and oxygen delivery to the placenta and fetus.
Choice C rationale
While uterine tachysystole (excessive frequency of contractions, greater than five in 10 minutes over 30 minutes) can cause late decelerations, palpating for it is not the absolute first action. The immediate priority is to improve fetal oxygenation by repositioning the mother. Palpation for tachysystole, however, is a quick assessment that should follow the repositioning intervention.
Choice D rationale
Increasing the infusion rate of the maintenance IV fluid (an IV fluid bolus) is a critical step in intrauterine resuscitation for late decelerations. It increases maternal blood volume, which can improve placental perfusion. However, repositioning the client is generally the most immediate, least invasive, and first step to correct or improve the blood flow to the placenta and fetus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"B"}}
Explanation
Explanation
- Moderate maternal bleeding
- In a patient with HELLP and thrombocytopenia, bleeding suggests coagulopathy (DIC) or placental abruption. This is a serious worsening sign.
- Ringing in ears (tinnitus)
- Could be a side effect of magnesium sulfate toxicity or a neurological symptom of worsening preeclampsia. Either way, it’s concerning and not a sign of improvement.
- Sharp, stabbing abdominal pain
- RUQ/epigastric pain worsening into sharp pain raises concern for liver capsule distension or rupture (life-threatening complication of HELLP) or placental abruption. This is a red flag.
- BP 180/100 mm Hg
- Despite antihypertensive therapy, this is severe hypertension (≥160/110 mm Hg). Indicates poor control and worsening maternal risk.
- FHR 80/min with absent variability
- This is severe fetal bradycardia with no variability, indicating fetal hypoxia/distress. This is an obstetric emergency.
- PT 12 seconds
- Within normal range (11–13.5 sec). This suggests no current coagulopathy and is the only stable/improving finding.
Almost all findings point to worsening maternal and fetal condition, except for the PT which is stable. The nurse should immediately notify the provider, anticipate emergency delivery (likely induction or cesarean), and continue close monitoring for magnesium toxicity and bleeding complications.
Correct Answer is B
Explanation
Choice A rationale
A nonreactive nonstress test (NST), defined by having fewer than two accelerations of at least 15 beats per minute (BPM) above baseline, lasting at least 15 seconds, within a 20-minute window, indicates potential fetal compromise or sleep state, leading to a maximum score of 0 on this component, thus not indicating well-being.
Choice B rationale
The biophysical profile (BPP) scores fetal movement with a maximum of 2 points for three or more discrete body or limb movements within a 30-minute period. The finding of four limb movements clearly meets this criterion and earns the full 2 points, reflecting an intact central nervous system and adequate fetal oxygenation, which is a sign of fetal well-being.
Choice C rationale
The BPP criterion for fetal breathing movements requires at least one episode of sustained movements for 30 seconds within the 30-minute observation period to score 2 points. The finding of 20 seconds is insufficient to meet this 30-second threshold, resulting in a score of 0 points for this component and thus not indicating full well-being.
Choice D rationale
The amniotic fluid index (AFI) measures the sum of the deepest vertical pockets of amniotic fluid in the four quadrants of the uterus. An AFI of 1 cm is significantly below the normal range of 5 cm to 25 cm, indicating oligohydramnios (low fluid). This finding scores 0 points on the BPP and suggests potential chronic fetal compromise or renal issues.
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