A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?

Administer oxygen at 10 L/min via nonrebreather facemask.

Initiate an amnioinfusion.

Instruct the client to bear down and push with contractions.

Place the client in a supine position.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Administering oxygen helps improve oxygenation to the fetus and is the priority intervention for late decelerations.

B. Amnioinfusion may be considered for variable decelerations caused by oligohydramnios but is not indicated for late decelerations.

C. Instructing the client to bear down and push with contractions is not appropriate for addressing late decelerations and may worsen fetal distress.

D. Placing the client in a supine position can exacerbate late decelerations by reducing blood flow to the uterus and should be avoided.

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Correct Answer is B

Explanation

Rationale:

A. A blood pressure of 120/70 mm Hg is within the normal range for a postpartum client and does not require immediate reporting to the provider.

B. Cool clammy skin may indicate hypoperfusion or inadequate blood flow, which could be a sign of hemorrhage or other circulatory issues. This finding should be reported promptly for further evaluation and intervention.

C. Moderate lochia serosa is a normal finding in the early postpartum period and does not typically require immediate reporting.

D. A heart rate of 89/min is within the normal range for a postpartum client and does not require immediate reporting to the provider.

A. Raw carrots B. Brown rice C. Fresh citrus fruits D. Fortified soy milk

Correct Answer is D

Explanation

Rationale:

A. Raw carrots are not a significant source of vitamin B12, which is typically lacking in a vegan diet.

B. Brown rice is a healthy grain but does not contain vitamin B12, which is necessary for those following a vegan diet.

C. Fresh citrus fruits provide vitamin C but not vitamin B12, which is important for individuals following a vegan diet.

D. Fortified soy milk is often enriched with vitamin B12, making it a suitable recommendation for individuals practicing a vegan diet who need to increase their intake of this nutrient.

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A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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