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.
The Correct Answer is A
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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Related Questions
Correct Answer is B
Explanation
Rationale:
A. Back pain following intercourse at 36 weeks of gestation may be common and is not typically indicative of an urgent issue.
B. Severe vomiting in early pregnancy could indicate hyperemesis gravidarum, which may require immediate assessment and intervention to prevent dehydration and electrolyte imbalances.
C. Frequent urination at 10 weeks of gestation is common due to hormonal changes and increased pressure on the bladder from the growing uterus, but it does not typically require immediate assessment unless accompanied by other concerning symptoms.
D. Periodic tingling of the fingers at 24 weeks of gestation could be due to carpal tunnel syndrome, which is common in pregnancy but does not usually require urgent assessment unless severe or accompanied by other symptoms.
Correct Answer is B
Explanation
Rationale:
A. Polycythemia: Polycythemia, an elevated red blood cell count, is not typically associated with forceps-assisted birth.
B. Facial palsy:
Correct answer. Facial palsy, or weakness or paralysis of facial muscles, can occur as a complication of forceps-assisted birth due to pressure or trauma to the facial nerve during delivery.
C. Bronchopulmonary dysplasia: Bronchopulmonary dysplasia is a lung condition primarily affecting premature infants and is not directly related to the method of delivery.
D. Hypoglycemia: Hypoglycemia, low blood sugar levels, can occur in newborns for various reasons but is not specifically associated with forceps-assisted birth unless there are other complicating factors.
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