A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse
take first?

Turn the client onto her side.

Increase the client's IV fluid infusion rate.

Administer oxygen to the client.

Palpate the client's uterus.

Answer and Explanation

The Correct Answer is A

Choice A:The priority action when the fetal monitor tracing shows late decelerations after the client's membranes rupture is to turn the client onto her side. This position change helps relieve pressure on the vena cava and improves blood flow to the fetus.
Choice B: Increasing the client's IV fluid infusion rate is not the first priority in this situation, as late decelerations are primarily related to uteroplacental insufficiency rather than maternal hydration status.
Choice C: Administering oxygen to the client is important, but turning the client onto her side should be the first action to improve fetal oxygenation.
Choice D: Palpating the client's uterus is not the first priority in the presence of late

decelerations. The focus should be on relieving the compression on the vena cava and improving fetal oxygenation by changing the client's position.

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Correct Answer is A

Explanation

Choice A: The client should not lie on her back during the NST because the supine position can compress the vena cava and reduce blood flow to the placenta and the baby. The NST is typically done with the client in a semireclined or left lateral position to ensure optimal blood flow to the baby.

Choice B: Monitoring the baby's heart rate is a correct statement and a standard part of the NST procedure.

Choice C: The duration mentioned (20 to 30 minutes) is accurate for the average NST timeframe.

Choice D: Scheduling the NST when the baby is usually active is also a correct statement, as fetal movement during the test is an important aspect of evaluating fetal wellbeing.

A. All of the clients B. A client who has a history of preterm labor C. A client who has mitral valve prolapse D. A client who has been exposed to AIDS

Correct Answer is A

Explanation

A) All of the clients: Maternal serum alphafetoprotein (MSAFP) screening is a routine prenatal test offered to all pregnant women, usually between 15 and 20 weeks of gestation. It is used to screen for certain fetal anomalies, including neural tube defects such as spina bifida and anencephaly. Regardless of a client's medical history or risk factors, the MSAFP screening is typically recommended for all pregnant individuals as part of routine prenatal care.
B) A client who has a history of preterm labor: Preterm labor history is not a specific indication for MSAFP screening. This test is primarily used to screen for fetal anomalies, not preterm labor risk assessment.
C) A client who has mitral valve prolapse: Mitral valve prolapse is also not an indication for MSAFP screening. The test is focused on assessing fetal health and not maternal heart conditions.
D) A client who has been exposed to AIDS: MSAFP screening is not related to maternal exposure to AIDS. It is a test focused on assessing the fetus's risk of certain congenital abnormalities.

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A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

Nursing Test Bank

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A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse
take first?