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 C
Explanation
Rationale:
A. A client who has alcoholic pancreatitis: Alcoholic pancreatitis does not pose a risk of teratogenicity or infectious transmission to a pregnant nurse. Standard precautions are sufficient, making this assignment safe for a pregnant nurse.
B. A client who has latent tuberculosis: Latent TB is not contagious, as the bacteria are inactive and the client cannot transmit the infection. A pregnant nurse can safely care for this client with standard precautions without increased risk.
C. A client who is recovering from shingles: Shingles (herpes zoster) is caused by reactivation of the varicella-zoster virus and can be transmitted via direct contact with lesions. Pregnant nurses who have not had chickenpox or the varicella vaccine are at risk for serious complications, so this client should be assigned to a non-pregnant nurse.
D. A client who has HIV: HIV is transmitted through blood and body fluids, and standard precautions effectively protect healthcare workers. There is no contraindication for a pregnant nurse to care for a client with HIV using proper infection control measures.
Correct Answer is A
Explanation
Rationale:
A. Banana slices: Soft, manageable, and cut into small pieces, banana slices are safe for a toddler to pick up and self-feed. They promote fine motor skill development and independence while minimizing the risk of choking.
B. Popcorn: Popcorn is a choking hazard for toddlers because it is small, hard, and easily inhaled. It is unsafe for children under 4 years and should be avoided when promoting independent eating.
C. Grapes: Whole grapes are also a significant choking risk. If given, they must be cut into small, manageable pieces, so serving them whole does not support safe independent eating.
D. Hot dog: Whole hot dogs are cylindrical and firm, posing a high choking risk for toddlers. Even when sliced lengthwise or chopped, supervision is required, and they are less suitable for promoting safe self-feeding compared to soft fruits like banana slices.
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