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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Report of perineal pain as 0 on a scale of 0 to 10: Perineal pain is more directly related to the effects of spinal anesthesia rather than fluid status. A decrease in perineal pain would be expected after the administration of spinal anesthesia, but it may not specifically indicate the effectiveness of the IV bolus.
B. Report of relief of pruritus: Pruritus (itching) is a common side effect of spinal anesthesia. Relief of pruritus can be expected after the administration of spinal anesthesia, but it is not a direct indicator of the effectiveness of the IV bolus.
C. Increased urinary output: Increased urinary output may indicate improved renal perfusion or fluid balance but is not a specific indicator of the effectiveness of the IV bolus in the context of spinal anesthesia for labor.
D. Blood pressure 110/70 mm Hg: This is the correct answer. Blood pressure is an important parameter to monitor, especially after administering an IV bolus of fluids. A blood pressure within the normal range (110/70 mm Hg) suggests that the bolus has been effective in addressing any hypovolemia or dehydration.
Correct Answer is A
Explanation
A. Uterine tenderness is a common finding in endometritis. This inflammation of the endometrial lining can cause tenderness upon palpation of the uterus.
B. Temperature 37.4o C (99.3 F): Fever is a common symptom of endometritis. The body's response to infection often includes an elevated temperature.
C. WBC count 9000/mm3: In endometritis, there is typically an elevated white blood cell count as the body responds to the infection. A count of 9000/mm3 is within the normal range and may not be indicative of infection, making this choice less likely.
D. Scant lochia: Endometritis is associated with an increase in lochial flow rather than a decrease. Lochia may be increased in amount and foul-smelling in cases of endometritis. Scant lochia is more likely to be associated with other postpartum conditions but not necessarily endometritis.
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