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 A

Explanation

A. Yellowed sclera : Yellowed sclera (the white part of the eyes) can indicate jaundice in a newborn. Jaundice is caused by elevated levels of bilirubin and may signify various underlying conditions, including an excessive breakdown of red blood cells, liver immaturity, or other issues. Prompt notification of the healthcare provider is necessary to evaluate and manage jaundice appropriately.

B. Stooling after each breastfeeding: Stooling after each breastfeeding session is a common and expected occurrence in newborns. Breastfed babies often pass stools frequently, and this is generally not a cause for concern unless there are other associated symptoms.

C. Intermittent crossing of eyes: Occasional intermittent crossing of eyes can be normal in newborns. However, if persistent or accompanied by other concerning signs, it might require evaluation, but it's not typically an immediate concern.

D. Voids eight to ten times per day: A healthy newborn typically voids frequently throughout the day. Eight to ten times per day is within the expected range for a newborn's urinary output and might not be a cause for immediate concern.

A. I will receive a series of three immunisations and each one sill be a month apart B. I should avoid becoming pregnant for at least 1 month following the immunisation C. I should avoid breastfeeding for 2 weeks following the immunization D. I will report joint pain that develops after the immunization to my provider immediately

Correct Answer is B

Explanation

A. I will receive a series of three immunizations, and each one will be a month apart: This statement is not accurate for rubella immunization. The MMR vaccine is usually administered as a single injection.

B. I should avoid becoming pregnant for at least 1 month following the immunization

Rubella immunization is typically administered as the measles, mumps, and rubella (MMR) vaccine. The statement indicating understanding reflects awareness of the importance of avoiding pregnancy for a certain period after receiving the rubella immunization due to potential risks to the developing fetus.

C. I should avoid breastfeeding for 2 weeks following the immunization: Breastfeeding is not a contraindication after receiving the rubella immunization. In fact, breastfeeding is generally not affected, and mothers can continue to breastfeed.

D. I will report joint pain that develops after the immunization to my provider immediately: Joint pain is a potential side effect of the rubella vaccine. Reporting joint pain to the provider is essential for monitoring and addressing any adverse reactions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a new parent about findings that require notification of the newborn's provider. Which of the following newborn clinical manifestations should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements indicates understanding of the teaching?

Correct Answer is B

Explanation

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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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