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 B
Explanation
A) The largest fetal diameter has passed through the pelvic outlet: This is an incorrect
interpretation of station 0. Station 0 means that the presenting part is at the level of the ischial spines, not fully descended through the pelvic outlet.
B) The lowermost portion of the presenting part is at the level of the ischial spines: This is the correct interpretation of station 0. Station 0 is the landmark at which the presenting part is at the level of the ischial spines in the maternal pelvis.
C) The posterior fontanel is palpable: The position of the fontanelle is not related to the station of the presenting part.
D) The fetal head is in the left occiput posterior position: The position of the fetal head is not indicated by the station measurement.
Correct Answer is D
Explanation
Choice D: Leopold maneuvers are used to determine the fetal position and presentation by palpating the abdomen. ROA stands for Right Occiput Anterior, which means the baby's head is presenting and facing towards the mother's right side (Occiput) and positioned anteriorly (front of the pelvis).
This position is a common and favorable presentation for a vaginal delivery.
Choice A: Shoulder presentation is when the baby is presenting with the shoulder rather than the head. It is an abnormal presentation and requires a cesarean delivery.
Choice B: Mentum presentation is a type of face presentation, where the baby's chin (mentum) is presenting instead of the head. It is also an abnormal presentation and usually requires a cesarean delivery.
Choice C: Breech presentation is when the baby's buttocks or feet are presenting first instead of the head. It is another abnormal presentation that may require a cesarean delivery or careful vaginal delivery with a skilled healthcare provider.
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