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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Subcutaneous injections are not typically used for newborns due to their lack of subcutaneous fat.
Choice B rationale:
The vastus lateralis muscle is the preferred site for IM injections in newborns due to its size and location.
Choice C rationale:
The deltoid is not a recommended site for IM injections in newborns due to its small size.
Choice D rationale:
As mentioned earlier, subcutaneous injections are not typically used for newborns.
Correct Answer is A
Explanation
Choice A rationale:
The McRoberts maneuver involves an obstetrician or other healthcare provider flexing the thighs of a pregnant person toward their abdomen. This maneuver helps to rotate the pelvis and open the sacrum to release the baby’s shoulder.
Choice B rationale:
Applying pressure on the client’s suprapubic area is not part of the McRoberts maneuver. However, when coupled with suprapubic pressure, the effectiveness of the McRoberts maneuver increases to 90%1.
Choice C rationale:
Moving the client onto their hands and knees is not part of the McRoberts maneuver. The maneuver involves pressing the client’s legs against their abdomen.
Choice D rationale:
Applying pressure to the client’s fundus is not part of the McRoberts maneuver. The maneuver involves pressing the client’s legs against their abdomen.
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