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 C
Explanation
Choice A rationale:
Oatmeal is a good source of fibre, but its fibre content per cup is not as high as some other options.
Choice B rationale:
Cabbage is a healthy choice with some fibre content, but it does not have as much fibre per cup as lentils.
Choice C rationale:
Lentils have the highest fibre content per cup compared to the other options listed. They are rich in both soluble and insoluble fibre, which helps promote bowel regularity and alleviate constipation.
Choice D rationale:
Asparagus is a nutritious vegetable but does not have as much fibre per cup as lentils.
Correct Answer is A
Explanation
The correct answer is choice a. Provide the client with a cool sitz bath.
Choice A rationale:
A cool sitz bath can help reduce swelling and provide pain relief for a client with a fourth-degree laceration of the perineum. Cooling the area can also help minimize inflammation and promote healing.
Choice B rationale:
Methylergonovine is typically used to prevent or treat postpartum hemorrhage by causing uterine contractions. It is not indicated for the management of perineal lacerations.
Choice C rationale:
Applying a moist, warm compress to the perineum is not recommended immediately postpartum for a fourth-degree laceration, as it can increase swelling and discomfort. Cool treatments are preferred initially.
Choice D rationale:
Applying povidone-iodine to the perineum is not a standard practice for managing perineal lacerations. It can cause irritation and is not necessary for wound care in this context.
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