A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take?

Administer oxygen via a face mask

Decrease the rate of IV fluids

perform fetal scalp stimulation

Elevate the client’s head

Answer and Explanation

The Correct Answer is A

A. Administer oxygen via a face mask: This is the correct answer. Administering oxygen helps improve oxygenation to the fetus and is a standard intervention for late decelerations.

B. Decrease the rate of IV fluids: Decreasing IV fluids is not typically the first intervention for late decelerations. The primary goal is to improve oxygenation to the fetus, and increasing or maintaining maternal blood volume is important.

C. Perform fetal scalp stimulation: Fetal scalp stimulation is not the first-line intervention for late decelerations. It is more commonly used for assessing fetal well-being and responsiveness during the labor process.

D. Elevate the client’s head: Elevation of the client's head is not the recommended position for addressing late decelerations. Placing the client in a side-lying position is more appropriate to relieve pressure on the vena cava.

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Correct Answer is B

Explanation

A. Select a 21-gauge needle to perform the procedure: The size of the needle used for a heel stick typically ranges between 23 and 25 gauge. A 21-gauge needle is larger and may cause more discomfort to the newborn.

B. Puncture the lateral side of the heel for the procedure: The lateral (outer) side of the heel is the recommended site for a heel stick in a newborn. This area is less sensitive, and puncturing the lateral side helps avoid injury to the medial (inner) side where important structures are located.

C. Apply an alcohol pad to the site after the procedure: Applying an alcohol pad after the procedure is not necessary and may cause unnecessary discomfort to the newborn. The puncture site can be gently blotted with a gauze pad if needed.

D. Place a cool cloth at the site for 15 minutes before the procedure: Placing a cool cloth before the procedure is not recommended. Cooling the site may cause vasoconstriction, making it more difficult to obtain an adequate blood sample. It's generally better to warm the heel, for example, by using a warm cloth, to promote blood flow.

A. The client cleans the perineum with a squeeze bottle after urinating B. The client as changing the perineal pad once daily C. The client as using witch hazel pads on the perineum D. The client's perineal suture line is well-approximated

Correct Answer is B

Explanation

A. The client cleans the perineum with a squeeze bottle after urinating: This action is appropriate for postpartum perineal care. Using a squeeze bottle to cleanse the perineum with warm water after urination helps maintain cleanliness without causing trauma to the area.

B. The client is changing the perineal pad once daily: Changing the perineal pad once daily is not optimal for wound healing. Postpartum perineal wounds require frequent changing of pads to maintain cleanliness, prevent infection, and promote healing.

C. The client is using witch hazel pads on the perineum: Using witch hazel pads is a common practice for postpartum perineal care. Witch hazel has a soothing effect and can help reduce inflammation and discomfort without negatively affecting wound healing.

D. The client's perineal suture line is well-approximated: A well-approximated perineal suture line is a positive finding, indicating that the edges of the wound are properly aligned and closed, which supports the healing process.

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A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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