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 D
Explanation
Rationale:
A. “Our children can stay up as late as they prefer.” This statement reflects a permissive parenting style, where few rules are enforced and children have significant freedom. Parents in this style often avoid setting firm boundaries, which contrasts sharply with the strict control seen in authoritarian parenting.
B. “Our children are allowed to make their own choices.” This reflects an authoritative parenting style, which balances independence with guidance. Authoritative parents encourage decision-making while still providing consistent rules and support. This collaborative, approach differs significantly from the rigid and demanding nature of authoritarian parenting.
C. “We make decisions as a family.” This statement also aligns with authoritative parenting, which values communication, mutual respect, and shared problem-solving. Children’s input is considered, helping them develop confidence and reasoning skills. Such family-centered decision-making is not present in authoritarian households.
D. “We expect our children to do what we say without any questions.” Authoritarian parenting focuses on obedience, strict rules, and limited negotiation. Children are expected to comply without explanation, and parents often enforce discipline rigidly. This style places emphasis on control rather than communication.
Correct Answer is C
Explanation
Rationale:
A. Calcium: While calcium is important for many bodily functions, it is not a primary indicator for monitoring hepatic encephalopathy. Calcium imbalances do not directly correlate with the severity or management of this condition.
B. Potassium: Potassium levels are important for overall electrolyte balance, but they are not specific to hepatic encephalopathy. Monitoring potassium is part of routine care but does not indicate the progression or severity of encephalopathy.
C. Ammonia: Elevated ammonia levels are a key contributor to hepatic encephalopathy. The liver normally converts ammonia to urea, and when liver function is impaired, ammonia accumulates, affecting neurological function. Monitoring ammonia helps assess severity and guide treatment interventions.
D. Glucose: While glucose monitoring is important in general care, it is not specific to hepatic encephalopathy. Hyper- or hypoglycemia may occur with liver disease but does not directly reflect the presence or progression of encephalopathy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.