A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor tracing. Which of the following actions should the nurse take?
Decrease maintenance IV solution infusion rate.
Place the client in a lateral position.
Administer oxygen via face mask at 2 L/min.
Administer misoprostol 25 mcg vaginally.
The Correct Answer is B
Choice A rationale:
Decreasing the maintenance IV solution infusion rate is not the appropriate action for addressing late decelerations of the fetal heart rate. Late decelerations are a concerning sign during labor, indicating possible fetal distress. This can be caused by inadequate oxygenation of the fetus, and reducing IV fluids would not directly address this issue.
Choice B rationale:
Placing the client in a lateral (side-lying) position is the correct action when late decelerations are observed. This position helps to improve uteroplacental blood flow and can relieve pressure on the inferior vena cava, thus increasing oxygen supply to the fetus.
Choice C rationale:
Administering oxygen via face mask at 2 L/min is not the priority action in response to late decelerations. While oxygen may be beneficial in certain situations, it is not the initial intervention for addressing fetal heart rate decelerations.
Choice D rationale:
Administering misoprostol 25 mcg vaginally is not appropriate for addressing late decelerations. Misoprostol is a medication used for cervical ripening and induction of labor, but it does not directly address fetal heart rate changes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Hct (hematocrit) of 34% is a normal finding during pregnancy. Normal ranges vary during pregnancy, but generally, a hematocrit between 33% to 45% is considered normal during the second trimester.
Choice B rationale:
BUN (blood urea nitrogen) of 25 mg/dL should be reported to the provider. BUN measures kidney function, and during pregnancy, values above 20 mg/dL may indicate possible impaired kidney function, which requires further evaluation.
Choice C rationale:
Platelets of 170,000/mm³ are within the normal range during pregnancy. The normal platelet count during pregnancy is typically between 150,000 to 400,000/mm³.
Choice D rationale:
HbA1c (glycated hemoglobin) of 6% is a good indicator of blood sugar control and is within the target range for a pregnant woman with diabetes. The target HbA1c level for pregnant women with diabetes is usually around 6% or lower.
Correct Answer is A
Explanation
Choice A rationale:
Vibroacoustic stimulation is an appropriate action to perform during a nonstress test if there are no fetal heart rate accelerations. It involves using sound or vibration to stimulate the fetus, potentially eliciting the desired heart rate accelerations.
Choice B rationale:
Placing the client in the Trendelenburg position is not indicated in this situation. It may not benefit the fetus and is not a standard intervention for nonreactive nonstress test results.
Choice C rationale:
Conducting a vaginal exam is not relevant to the situation described in the question. A nonreactive nonstress test does not require a vaginal exam.
Choice D rationale:
Collecting a specimen for an indirect Coombs test is not necessary for this scenario. The test result would not provide information relevant to the nonreactive nonstress test.
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