A nurse is caring for a client who is receiving oxytocin for the induction of labor and notes late decelerations of the fetal heart rate on the monitor tracing. The nurse should take which of the following actions?
Administer misoprostol 25 mcg vaginally.
Place the client in a lateral position.
Administer oxygen via a face mask at 2 L/min.
Decrease the maintenance IV solution infusion rate.
The Correct Answer is B
Late decelerations are a type of fetal heart rate (FHR) pattern that indicate fetal hypoxia (lack of oxygen) due to uteroplacental insufficiency (decreased blood flow to the placenta). They are defined as a gradual decrease in FHR that occurs after the peak of a uterine contraction and returns to baseline after the end of the contraction¹. Late decelerations are associated with adverse neonatal outcomes, such as low Apgar scores, acidosis, and neonatal intensive care unit admission².
The nurse should take immediate actions to improve fetal oxygenation and blood flow when late decelerations are detected. The first and most important action is to place the client in a lateral position, either left or right, to reduce compression of the inferior vena cava and increase uterine perfusion. This can improve fetal oxygenation and reduce the severity of late decelerations¹³.
The other actions that the nurse should take are:
- Discontinue oxytocin infusion if it is being used for induction or augmentation of labor, as it can cause uterine tachysystole (excessive contractions) and worsen uteroplacental insufficiency¹³.
- Administer oxygen to the client at 8 to 10 L/min via a nonrebreather face mask to increase maternal oxygen saturation and fetal oxygen delivery¹³.
- Increase intravenous (IV) fluid infusion rate to maintain maternal hydration and blood pressure, which can improve uterine blood flow¹³.
- Notify the provider and prepare for possible operative delivery if late decelerations persist or fetal distress occurs¹³.
- Provide emotional support and reassurance to the client and family, as late decelerations can cause anxiety and fear⁴.
The other options are not actions that the nurse should take:
- a) Administer misoprostol 25 mcg vaginally. This is not correct because misoprostol is a medication that is used to induce labor by ripening the cervix and stimulating contractions. It is not indicated for late decelerations and can cause uterine hyperstimulation and fetal distress⁵.
- c) Administer oxygen via a face mask at 2 L/min. This is not correct because this is too low of an oxygen flow rate to improve fetal oxygenation. The recommended oxygen flow rate for late decelerations is 8 to 10 L/min via a nonrebreather face mask¹³.
- d) Decrease the maintenance IV solution infusion rate. This is not correct because this can cause maternal dehydration and hypotension, which can reduce uterine blood flow and worsen fetal hypoxia. The nurse should increase the IV fluid infusion rate to maintain maternal hydration and blood pressure¹³.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Hypoglycemia is a condition in which the blood sugar (glucose) level is too low. Glucose is the main source
of energy for the brain and the body. Newborns need a steady supply of glucose to maintain normal body
functions and growth. Hypoglycemia can occur in newborns for various reasons, such as prematurity, infection, birth asphyxia, maternal diabetes, or inadequate feeding¹.
Hypoglycemia can cause various symptoms in newborns, depending on the severity and duration of the low blood sugar level. Some of the common symptoms include:
- Jitteriness or tremors
- Irritability or crying
- Lethargy or sleepiness
- Poor feeding or sucking
- Low body temperature
- Pale or blue skin color
- Sweating
- Rapid breathing or heart rate
- Seizures or coma
Jitteriness is one of the earliest and most frequent signs of hypoglycemia in newborns². It is caused by the stimulation of the nervous system by low blood sugar levels. Jitteriness can be distinguished from seizures by several features, such as:
- Jitteriness is provoked by stimuli, such as noise or touch, while seizures occur spontaneously
- Jitteriness stops when the stimulus is removed or when the baby is held, while seizures persist
- Jitteriness involves rapid movements of the limbs, chin, or trunk, while seizures involve rhythmic jerking of
the limbs or eyes
- Jitteriness does not affect the level of consciousness, while seizures may cause the baby to be unresponsive
The other options are not typical signs of hypoglycemia in newborns and have different causes:
a) Petechiae are small red or purple spots on the skin caused by bleeding under the skin. They can occur due to trauma during delivery, infection, clotting disorders, or low platelet count.
b) Increased muscle tone is a state of increased tension or stiffness in the muscles. It can occur due to neurological disorders, such as cerebral palsy, spinal cord injury, or brain damage.
d) Abdominal distention is a condition in which the abdomen becomes swollen or enlarged. It can occur due to various causes, such as intestinal obstruction, gas accumulation, organ enlargement, fluid accumulation, or tumor.
Correct Answer is C
Explanation
Facial petechiae are small, red or purple spots of bleeding under the skin or mucous membranes of the face. They are caused by the rupture of tiny blood vessels called capillaries. Facial petechiae can occur as a result of prolonged straining, such as during childbirth, vomiting, coughing, or crying¹. The increased pressure in the veins of the head and neck can cause the capillaries to burst, resulting in petechiae. Facial petechiae are usually harmless and resolve on their own without treatment.
The other options are not related to prolonged straining and have different causes and appearances:
a) Periauricular papillomas are benign, wart-like growths that occur near the ear. They are caused by human papillomavirus (HPV) infection and may be present at birth or develop later in life. They are usually painless and do not bleed⁴.
b) Erythema toxicum is a common skin condition in newborn babies. It causes a rash and small, fluid-filled bumps that may appear on the face, limbs, or chest. It is not caused by bleeding, infection, or allergy, but by an unknown mechanism. It does not cause discomfort to the baby and clears up without treatment within one to two weeks⁵.
d) Telangiectatic nevi are birthmarks that are caused by dilated blood vessels near the surface of the skin. They appear as red or purple patches or patterns on the skin that do not fade with pressure. They are present at birth and may grow in proportion to the child's growth. They are not associated with bleeding or infection and do not require treatment unless they cause cosmetic concerns⁶.
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