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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Weak cry
While infants with neonatal abstinence syndrome (NAS) may exhibit irritability and excessive crying, a weak cry specifically is not typically associated with NAS. A weak cry could indicate other issues such as respiratory distress or neurological problems, but it is not a characteristic manifestation of NAS.
B. Absent Moro reflex
The Moro reflex is a normal primitive reflex present in newborns, involving the sudden extension and then flexion of the infant's arms in response to a sensation of falling or a loud noise. While NAS can affect the nervous system, leading to irritability and tremors, it typically does not cause the complete absence of the Moro reflex. Thus, this choice is less likely.
C. Respiratory rate of 30/min
A respiratory rate of 30/min in a newborn is within the normal range. While NAS can sometimes cause respiratory distress, it would typically present as symptoms such as rapid breathing, not necessarily a specific rate like 30/min. Therefore, this choice is not strongly associated with NAS.
D. Poor feeding
Poor feeding is a common manifestation of neonatal abstinence syndrome (NAS). Infants born to mothers who used methadone during pregnancy often experience withdrawal symptoms, including irritability and gastrointestinal issues, which can interfere with their ability to feed effectively. Poor feeding is a hallmark sign of NAS and is frequently observed in affected newborns.
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.
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