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.
Elevate the client’s head.
Perform fetal scalp stimulation.
Administer oxygen via a face mask.
The Correct Answer is D
Choice A rationale
Decreasing the rate of IV fluids would not address the issue of late decelerations, which are a sign of fetal hypoxia.
Choice B rationale
Elevating the client’s head would not address the issue of late decelerations.
Choice C rationale
Performing fetal scalp stimulation is used to assess fetal well-being when the tracing is nonreactive, not when late decelerations are present.
Choice D rationale
Administering oxygen via a face mask is the correct answer. This increases maternal oxygen saturation, which can help increase oxygen delivery to the fetus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
Step 1 is to determine the amount of medication needed per dose. The prescription is for 250 mg of metronidazole, but the available tablets are 500 mg each. So, the calculation is 250 mg ÷ 500 mg/tablet. The result is 0.5 tablet per dose.
Correct Answer is D
Explanation
Choice A rationale
A pudendal nerve block is not typically used for postpartum perineal pain management. It is more commonly used during labor to relieve pain in the perineum and vagina.
Choice B rationale
While hydrogel pads can provide cooling relief, they are not typically used for third-degree perineal lacerations. These types of lacerations often require more intensive interventions.
Choice C rationale
Applying a warm pack to the perineum can help with discomfort, but it is not the primary intervention for a third-degree perineal laceration.
Choice D rationale
Witch hazel pads are often recommended for postpartum perineal care. They can provide relief from soreness, reduce inflammation, and promote healing.
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