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 D
Explanation
Rationale:
A. Raw carrots: While carrots are nutritious, they are not significant sources of vitamin B12, which is typically lacking in a vegan diet.
B. Brown rice: Brown rice is a whole grain and a good source of certain B vitamins like niacin and thiamine, but it does not contain vitamin B12, which is important for those following a vegan diet.
C. Fresh citrus fruits: Citrus fruits are rich in vitamin C but do not provide significant amounts of vitamin B12.
D. Fortified soy milk:
Correct answer. Fortified soy milk is often enriched with vitamin B12, making it a suitable choice for individuals following a vegan diet who may struggle to obtain adequate amounts of this vitamin from plant-based sources.
Correct Answer is C
Explanation
Rationale:
A. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, typically in the fallopian tube. This scenario does not match the clinical presentation described.
B. Incompetent cervix is characterized by painless cervical dilation in the second trimester and is not relevant to the clinical situation described.
C. Postpartum hemorrhage is a risk when a woman is in advanced labor with significant cervical dilation. The nurse should be vigilant for signs of hemorrhage during labor and after delivery.
D. Hyperemesis gravidarum is severe nausea and vomiting during pregnancy and is not directly related to the client's current labor status.
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