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
This is the method that the nurse should use to elicit the Moro reflex. The Moro reflex, or startle reflex, is an involuntary motor response that infants develop shortly after birth. It is a response to a sudden loss of support or extremely sudden stimulation¹. A loud noise above the newborn can trigger the Moro reflex by startling the infant. The Moro reflex involves three distinct components: spreading out the arms (abduction), pulling the arms in (adduction), and crying (usually)².
The other options are not correct because they do not elicit the Moro reflex.
a) Turn the newborn's head to one side.
This does not elicit the Moro reflex, but rather the tonic neck reflex. The tonic neck reflex occurs when the infant turns their head to one side and assumes a "fencing" posture, with the arm and leg on the same side extended and the opposite arm and leg flexed.
b) Touch the newborn's cheek with a finger.
This does not elicit the Moro reflex, but rather the rooting reflex. The rooting reflex occurs when the infant turns their head and opens their mouth in response to a touch on their cheek or mouth. This reflex helps the infant locate and latch onto a nipple for feeding³.
d) Tap the newborn's forehead with a finger.
This does not elicit the Moro reflex, but rather the glabellar reflex. The glabellar reflex occurs when the infant blinks in response to a tap on their forehead or bridge of their nose. This reflex helps protect the eyes from injury³.
Correct Answer is C
Explanation
Postpartum hemorrhage (PPH) is severe vaginal bleeding after childbirth. It can occur within 24 hours of delivery (primary PPH) or up to 12 weeks postpartum (secondary PPH) ¹. PPH can cause serious complications and even death if not treated promptly and effectively¹.
The client in the question is at risk for PPH because she has a rapid labor and a high degree of cervical dilation. These factors can cause uterine atony, which is the failure of the uterus to contract and compress the blood vessels after delivery. Uterine atony is the most common cause of PPH, accounting for up to 80% of cases². Other risk factors for PPH include placental abruption, placenta previa, overdistended uterus, multiple pregnancy, prolonged labor, operative delivery, retained placenta, coagulation disorders, and infection²³.
a) Hyperemesis gravidarum is a condition of severe nausea and vomiting during pregnancy that can cause dehydration, electrolyte imbalance, weight loss, and nutritional deficiencies. It usually occurs in the first trimester and resolves by the second trimester. It is not related to PPH⁴.
b) Ectopic pregnancy is a condition where the fertilized egg implants outside the uterus, usually in the fallopian tube. It can cause abdominal pain, vaginal bleeding, and rupture of the tube. It is a medical emergency that requires prompt diagnosis and treatment. It occurs in early pregnancy and cannot be diagnosed at 12 weeks of gestation by amniocentesis.
d) Incompetent cervix is a condition where the cervix dilates prematurely and painlessly during pregnancy, leading to preterm labor and delivery or pregnancy loss. It usually occurs in the second trimester and can be treated with cervical cerclage or progesterone. It is not associated with PPH.
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