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.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Telling a grieving mother that not holding her baby will make letting go much harder can be seen as insensitive and may not be true for all individuals. Each person’s grief process is unique.
Choice B rationale
Assuring the mother that she will be able to have another baby when she’s ready may be seen as dismissive of her current loss. It’s important to acknowledge the pain of losing this specific child, rather than focusing on future children.
Choice C rationale
This is the correct answer. Offering the mother the opportunity to bathe and dress her baby can provide a sense of closure and a chance to say goodbye. It allows the mother to care for her baby in the short time they have together.
Choice D rationale
While some parents may find comfort in naming their baby, it should not be presented as something the mother “should” do. The decision to name the baby is a personal one and should be left up to the parents.
Correct Answer is C
Explanation
Choice A rationale
Synchronized breathing is not specifically required during hypnosis. Hypnosis involves a state of deep relaxation and focused concentration.
Choice B rationale
While focusing on controlling body functions can be a part of some relaxation and pain management techniques, it is not the primary component of hypnosis. Hypnosis is more about reaching a state of deep relaxation and altering one’s state of consciousness.
Choice C rationale
Hypnosis can indeed be beneficial if practiced during the prenatal period. Regular practice can help enhance the effectiveness of hypnosis during labor by making it easier for the person to reach the hypnotic state.
Choice D rationale
This statement is not entirely accurate. Hypnosis can be an effective method for managing labor pain for some individuals. However, like all pain management techniques, its effectiveness can vary from person to person.
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