A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take?
Prepare for an emergency cesarean birth.
Assist the client to a knee-chest position.
Prepare the client for continuous internal monitoring.
Continue observing the fetal heart rate.
The Correct Answer is D
A. Early decelerations are typically benign and often associated with head compression, not necessitating an emergency cesarean birth.
B. A knee-chest position is generally used for variable decelerations but is not indicated for early decelerations.
C. Continuous internal monitoring may be necessary in certain situations, but in the case of early decelerations, it is not an immediate intervention.
D. Early decelerations usually require continued monitoring without immediate intervention as they typically resolve spontaneously with contractions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Bradycardia is not typically associated with pulmonary edema; instead, tachycardia is more common as the body tries to compensate for decreased oxygenation.
B. Wheezing may occur in certain respiratory conditions but is not a classic finding in pulmonary edema; instead, crackles or rales are more expected due to fluid accumulation.
C. Pale, dry skin is not characteristic of pulmonary edema; the client may present with cyanosis or clammy skin due to hypoxia.
D. Pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the alveoli and is often associated with acute heart failure.
Correct Answer is A
Explanation
A. Initiating the process to review the medical record is appropriate; clients have the right to access their medical information under HIPAA regulations, and the nurse can assist in starting that process.
B. While there are restricted parts of a medical record, the response lacks a proactive approach to assisting the client in accessing the information they have the right to view.
C. This response is dismissive of the client's request and does not provide an avenue for understanding the medical record better.
D. Although the provider can provide more detailed information about treatment, it does not
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