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?

Perform fetal scalp stimulation

Administer oxygen via a face mask.

Elevate the client's head.

Decrease the rate of IV fluids.

Answer and Explanation

The Correct Answer is B

A. Perform fetal scalp stimulation:

Fetal scalp stimulation involves applying pressure to the fetal scalp during a vaginal examination to elicit a response from the fetus, such as an acceleration of the fetal heart rate. While this can provide additional information about fetal well-being, it is not the initial priority when late decelerations are observed on the fetal monitor. The focus should first be on interventions aimed at improving fetal oxygenation to address the underlying cause of the late decelerations.

B. Administer oxygen via a face mask:

Administering oxygen to the mother is a priority intervention when late decelerations of the fetal heart rate are observed on the external fetal monitor. Late decelerations often indicate uteroplacental insufficiency, where the fetus is not receiving adequate oxygenation. Administering oxygen to the mother helps increase oxygen levels in her blood, improving oxygen delivery to the fetus and potentially mitigating the effects of uteroplacental insufficiency.

C. Elevate the client's head:

Elevating the client's head is not indicated when late decelerations are observed. This position could potentially compromise maternal-fetal circulation by reducing blood flow to the placenta. Maintaining a side-lying or semi-Fowler's position is often recommended to improve blood flow to the placenta and enhance fetal oxygenation.

D. Decrease the rate of IV fluids:

Adjusting the rate of IV fluids may be considered in some situations, such as if there is evidence of fluid overload or if the mother is receiving excessive amounts of IV fluids. However, it is not typically the initial intervention for addressing late decelerations. The focus should first be on interventions aimed at improving maternal-fetal oxygenation, such as administering oxygen and positioning the client appropriately.

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Correct Answer is ["B","C","F"]

Explanation

A. Thromboembolism:

Thromboembolism refers to the formation of blood clots (thrombi) that break loose and travel through the bloodstream, potentially causing blockages in blood vessels (embolism). While thromboembolism is a risk in pregnancy, especially in individuals with risk factors such as obesity or a history of thromboembolic events, there are no specific indications in the scenario provided that suggest an increased risk of thromboembolism for this client.

B. Electrolyte imbalance:

The client's persistent nausea, vomiting, and ketonuria indicate significant dehydration and electrolyte imbalances. Dehydration can lead to imbalances in electrolytes such as potassium, sodium, and chloride, which are essential for proper bodily function. Laboratory findings of low potassium (hypokalemia) and elevated blood urea nitrogen (BUN) support the presence of electrolyte imbalances. These imbalances can have serious consequences for both the client and the fetus, including cardiac arrhythmias, muscle weakness, and metabolic disturbances.

C. Fetal growth restriction:

Hyperemesis gravidarum, characterized by severe nausea and vomiting leading to dehydration and weight loss, is associated with an increased risk of fetal growth restriction. Inadequate maternal nutrition and dehydration can compromise fetal growth and development, potentially leading to a smaller-than-expected size for gestational age. The client's weight loss and ketonuria further support the possibility of fetal growth restriction due to insufficient nutrient intake and placental perfusion.

D. Polyhydramnios:

Polyhydramnios refers to an excess of amniotic fluid surrounding the fetus in the uterus. While hyperemesis gravidarum and dehydration can lead to maternal complications, such as electrolyte imbalances and fetal growth restriction, they are not typically associated with an increased risk of polyhydramnios. Polyhydramnios is more commonly linked to fetal anomalies, maternal diabetes, or fetal conditions that affect swallowing or fluid regulation, none of which are evident in the provided scenario.

E. Gestational diabetes mellitus:

Gestational diabetes mellitus (GDM) is a condition characterized by high blood sugar levels during pregnancy. While GDM can lead to various complications for both the mother and the fetus, including macrosomia (large birth weight), birth injuries, and neonatal hypoglycemia, there are no indications in the scenario provided that suggest an increased risk of GDM for this client.

F. Spontaneous abortion:

Hyperemesis gravidarum, with severe nausea, vomiting, and weight loss, is associated with an increased risk of spontaneous abortion or miscarriage. Dehydration, electrolyte imbalances, and maternal malnutrition can compromise maternal and fetal well-being, potentially leading to pregnancy loss. Therefore, the client is at an increased risk of spontaneous abortion due to the severity of her symptoms and the impact on her overall health and pregnancy.

A. Inform the client about the possible need for reduction of multiple fetuses. B. Instruct the client not to use donor oocytes. C. Instruct the client to avoid freezing embryos for possible use in the future. D. Inform the client that sperm will be introduced to the uterus during ovulation.

Correct Answer is A

Explanation

A. Inform the client about the possible need for reduction of multiple fetuses:

In vitro fertilization (IVF) can lead to the development of multiple embryos, increasing the risk of multiple gestation pregnancies, such as twins or triplets. Multiple gestations pose higher risks for both the mother and the babies, including preterm birth, low birth weight, and other complications. Therefore, the nurse should inform the client about the possibility of needing fetal reduction procedures to reduce the number of fetuses and minimize risks to both the mother and the remaining babies.

B. Instruct the client not to use donor oocytes:

Donor oocytes (eggs) are commonly used in IVF procedures, particularly for clients who have infertility related to egg quality or production issues. The decision to use donor oocytes should be based on individual circumstances and preferences. It is not appropriate for the nurse to instruct the client not to use donor oocytes without knowing the client's specific situation and preferences.

C. Instruct the client to avoid freezing embryos for possible use in the future:

Freezing embryos for future use, known as embryo cryopreservation, is a common practice in IVF. It allows for the preservation of embryos that are not transferred during the initial IVF cycle for potential use in subsequent cycles. Embryo cryopreservation can improve the chances of pregnancy without the need for additional ovarian stimulation and egg retrieval procedures. Therefore, instructing the client to avoid freezing embryos would not be appropriate advice.

D. Inform the client that sperm will be introduced to the uterus during ovulation:

This statement is incorrect. In IVF, fertilization typically occurs outside the body in a laboratory setting. The eggs retrieved from the ovaries are fertilized with sperm in a dish, and the resulting embryos are then transferred to the uterus. Sperm is not introduced to the uterus during ovulation in the context of IVF.

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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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Correct Answer is ["B","C","F"]

Explanation

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Correct Answer is A

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