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 D
Explanation
Choice A rationale
Chorionic villus sampling (CVS) is a prenatal test that diagnoses chromosomal abnormalities such as Down syndrome, as well as a host of other genetic disorders. While it can determine the sex of the baby, it is not typically used for this purpose.
Choice B rationale
The statement that one cannot have an amniocentesis until they are at least 35 years of age is incorrect. While it is true that amniocentesis is often offered to women over the age of 35 due to an increased risk of chromosomal abnormalities, it can be performed on anyone at risk, regardless of age.
Choice C rationale
Scheduling the procedure for later in the day is not typically how amniocentesis is planned. It is a medical procedure that requires careful planning and preparation. It is usually performed between the 15th and 20th weeks of pregnancy.
Choice D rationale
This is the correct answer. Amniocentesis is a prenatal test that allows doctors to diagnose a range of genetic and chromosomal disorders. It involves taking a small sample of the amniotic fluid that surrounds the baby in the uterus for testing. The procedure can indeed determine if the baby has genetic or congenital disorders.
Correct Answer is C
Explanation
Choice A rationale
Feeding the newborn 5 to 10 minutes per breast may not be sufficient for the baby to get all the necessary nutrients. It is generally recommended to allow the baby to feed until they naturally let go of the breast.
Choice B rationale
Expecting two to four wet diapers every 24 hours is not accurate for a breastfeeding newborn. A well-fed newborn will typically have at least six wet diapers a day.
Choice C rationale
This is the correct answer. It is generally recommended to allow the baby to feed at least every 3 hours. This ensures that the baby gets enough nutrients and helps stimulate milk production.
Choice D rationale
Offering the newborn 30 mL (1 oz) of water between feedings is not recommended. Breast milk or formula should be the primary source of hydration for a newborn.
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