A nurse is caring for a client who is receiving oxytocin and notes that the electronic fetal monitor shows persistent late decelerations. Which of the following actions should the nurse take?
Increase the rate of the oxytocin infusion.
Administer dinoprostone transvaginally
Place the client in a lateral position.
Assist the client to empty their bladder.
The Correct Answer is C
Rationale:
A. Increase the rate of the oxytocin infusion: Increasing oxytocin would intensify uterine contractions, which can worsen uteroplacental insufficiency and exacerbate late decelerations. This action is unsafe and contraindicated when late decelerations are present.
B. Administer dinoprostone transvaginally: Dinoprostone is used to ripen the cervix or induce labor, not to correct fetal distress caused by uteroplacental insufficiency. Administering it in this scenario would not address the underlying problem and could increase fetal risk.
C. Place the client in a lateral position: Lateral positioning improves uteroplacental blood flow and oxygen delivery to the fetus, which can reduce late decelerations. It is an immediate, safe, and effective nursing intervention to relieve fetal stress caused by decreased placental perfusion.
D. Assist the client to empty their bladder: While bladder distention can affect uterine contractions and comfort, it does not directly address late decelerations. Emptying the bladder may be beneficial for other reasons, but repositioning the client takes priority in improving fetal oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
Answer: 200 mL/hr
Calculation:
- Identify the total volume to be infused and the infusion time
Total Volume: 200 mL
Infusion Time: 60 minutes (1 hour)
- Calculate the infusion rate
Infusion Rate (mL/hr) = Total Volume ÷ Time (hr)
Infusion Rate = 200 ÷ 1
Infusion Rate = 200 mL/hr
Correct Answer is C
Explanation
Rationale:
A. Decide which clients should be transported for a higher level of care: Determining transport priorities is usually the responsibility of the incident command or emergency response team, not individual unit nurses. Unit nurses provide patient assessments and recommendations but do not independently make these critical decisions.
B. Act as a spokesperson to provide information to the media: Communication with the media is handled by designated hospital public relations or administration personnel to ensure consistent and accurate information. Unit nurses are not responsible for media interactions during a disaster.
C. Recommend to the provider a list of clients for early discharge: Unit nurses are familiar with clients’ conditions, stability, and care needs, making them well-suited to recommend which clients can be safely discharged early. This helps prioritize resources and bed availability during a disaster while maintaining patient safety.
D. Determine the need for additional providers: Assessing staffing needs is the responsibility of the nurse manager or disaster coordinator. Unit nurses provide information about patient care demands but do not make staffing deployment decisions during an emergency.
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