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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Retained bile in the liver results in delayed digestion: This statement is not related to the cause of heartburn.
B) Increased estrogen production causes increased secretion of hydrochloric acid: While hormonal changes during pregnancy can contribute to heartburn, it is specifically increased progesterone that leads to relaxation of the cardiac sphincter and delayed gastric emptying, which are more directly linked to heartburn.
C) Pressure from the growing uterus displaces the stomach: Uterine pressure on the stomach can lead to a feeling of fullness, but it is not the primary cause of heartburn during pregnancy.
D) Increased progesterone production causes relaxation of the smooth muscle relaxation of the cardiac sphincter and delayed gastric emptying: This is the correct answer. Increased progesterone levels during pregnancy relax the lower esophageal sphincter, leading to gastric acid reflux into the esophagus and causing heartburn.
Correct Answer is C
Explanation
A. "This always happens by the end of the first trimester of pregnancy.": Quickening typically occurs later in pregnancy, not by the end of the first trimester.
B. "This will occur during the last trimester of pregnancy.": Quickening occurs much earlier than the last trimester.
C. "This usually happens between the fourth and fifth months of pregnancy.": Quickening, which is the first perception of fetal movements by the mother, generally occurs between 16 to 20 weeks of gestation.
D. "This will happen once the uterus begins to rise out of the pelvis.": Quickening does not directly correlate with the rising of the uterus out of the pelvis.
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