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?
Decrease the rate of IV fluids.
Perform fetal scalp stimulation.
Administer oxygen via a face mask.
Elevate the client's head.
The Correct Answer is C
Choice A rationale:
Decreasing the rate of IV fluids would not address the issue of late decelerations, which indicate fetal hypoxia.
Choice B rationale:
Fetal scalp stimulation is used to assess fetal well-being, but it would not address the issue of late decelerations.
Choice C rationale:
Administering oxygen via a face mask can increase the amount of oxygen available to the fetus, potentially alleviating the hypoxia causing the late decelerations.
Choice D rationale:
Elevating the client’s head would not address the issue of late decelerations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Turning the newborn every 4 hours is not necessary during phototherapy. The aim of phototherapy is to expose the newborn’s skin to as much light as possible.
Choice B rationale:
Applying hydrating lotion to the newborn’s skin prior to treatment is not recommended. The aim of phototherapy is to expose the newborn’s skin to as much light as possible.
Choice C rationale:
Eye covers should be used to protect the newborn’s eyes from the light during phototherapy.
Choice D rationale:
Providing the newborn with 15 mL glucose water after each feeding is not necessary during phototherapy. The newborn may need to be fed more often to help get rid of the bilirubin in his or her bowel movements.
Correct Answer is A
Explanation
Choice A rationale:
Hypotension is a common adverse effect of epidural analgesia due to the blockage of sympathetic nerve fibers, which can lead to vasodilation and decreased cardiac output.
Choice B rationale:
Polyuria is not typically associated with epidural analgesia. It could be related to other factors such as fluid administration or underlying medical conditions.
Choice C rationale:
A fetal heart rate of 152/min is within the normal range (110-160 beats/min) and is not an adverse effect of epidural analgesia.
Choice D rationale:
A maternal temperature of 37.4° C (99.4° F) is within the normal range (36.1° C to 37.2° C or 97° F to 99° F) and is not an adverse effect of epidural analgesia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
