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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:

A. Uses the TPN IV tubing to administer the client's next dose of antibiotics: TPN lines should never be used for administering other medications or fluids because this increases the risk of contamination, infection, and incompatibility reactions. TPN requires dedicated IV access to maintain sterility and prevent complications such as sepsis.

B. Plans for a check of the client's fingerstick glucose level every 6 hr: Monitoring blood glucose regularly is essential during TPN administration because high dextrose concentrations can cause hyperglycemia. Checking every 4–6 hours aligns with safe monitoring practices and does not require intervention.

C. Gradually increases the TPN infusion rate each hour until the prescribed rate is achieved: Slowly titrating the TPN rate helps the client adjust to the high glucose content and reduces the risk of hyperglycemia or fluid overload. This demonstrates safe and appropriate administration practice.

D. Schedules a bag and tubing change for 24 hr after the start of the infusion: Changing the TPN solution and tubing every 24 hours is consistent with infection control guidelines. This action maintains sterility and prevents microbial growth, reflecting proper technique.

A. Remind the client to eat scheduled meals daily. B. Place the client in a supine position. C. Offer the client a blanket to keep warm. D. Speak in a loud tone when addressing the client.

Correct Answer is C

Explanation

Rationale:

A. Remind the client to eat scheduled meals daily.: As clients near the end of life, appetite naturally decreases due to metabolic changes and reduced physiologic demand. Encouraging scheduled meals can create discomfort or distress and does not improve outcomes. Supportive care focuses on comfort rather than forcing nutritional intake.

B. Place the client in a supine position.: A supine position can worsen respiratory effort, increase the sensation of breathlessness, and promote secretion pooling. Terminal clients often breathe more comfortably in semi-Fowler’s or side-lying positions, which help ease ventilation and support comfort-based care.

C. Offer the client a blanket to keep warm.: Clients at the end of life commonly experience decreased body temperature due to reduced circulation and metabolic slowing. Gently providing a blanket supports comfort without invasive measures. Maintaining warmth helps ease physical distress and aligns with palliative goals focused on dignity and relief.

D. Speak in a loud tone when addressing the client.: Hearing is often the last sense to diminish, so speaking loudly is unnecessary and may startle or distress the client. A calm, soft voice preserves a peaceful environment and promotes emotional comfort, supporting both the client and family during end-of-life care.

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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?

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