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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Reposition the client with one hip elevated or on her left side: This is the correct first priority action. The client's vital signs indicate hypotension (low blood pressure), which may be caused by supine hypotensive syndrome. This condition occurs when the pregnant uterus compresses the vena cava, reducing blood return to the heart and causing a drop in blood pressure. Repositioning the client on her left side or elevating one hip can relieve the pressure on the vena cava and
improve blood flow to both the mother and the baby.
B) Notify the provider of the findings: While it is essential to inform the provider about the client's status, the first priority is to address the potential cause of hypotension and maternal discomfort.
C) Ask the client if she needs pain medication: Pain management is essential, but the client's vital signs and potential hypotensive condition take precedence as the first priority.
D) Have the client empty her bladder: Emptying the bladder can help reduce pressure on the vena cava and may improve blood flow, but it is not the first priority action in this situation. Repositioning the client is the initial priority to relieve supine hypotensive syndrome.
Correct Answer is A
Explanation
A: Engaging in moderate physical activity during pregnancy, such as jogging, is generally safe and beneficial for pregnant women who have uncomplicated pregnancies. Staying hydrated, avoiding excessive exertion, and preventing overheating are important considerations during exercise.
B: The use of saunas and hot tubs during pregnancy is generally not recommended at any trimester, as they can cause hyperthermia and pose risks to the developing fetus.
C: Limiting exercise to only stretching on a mat is not appropriate during pregnancy. Regular physical activity is generally encouraged, provided there are no specific contraindications or complications.
D: Completely avoiding exercise during pregnancy is not recommended, as moderate and appropriate physical activity can have various benefits for both the mother and the baby.
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