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 C,A,B,D,E
Explanation
C. Instruct the client to empty their bladder.
A. Position the client supine with knees flexed and place a small rolled towel under one of their hips.
B. Palpate the fetal part positioned in the fundus.
D. Palpate the fetal parts along both sides of the uterus.
E. Palpate the fetal part positioned above the symphysis pubis.
Correct Answer is B
Explanation
Rationale:
A. Massaging the client's fundus is not indicated for hypotension following epidural anesthesia.
Fundal massage is typically performed to prevent or manage uterine atony and postpartum hemorrhage.
B. Turning the client to a side-lying position is a recommended intervention for hypotension following epidural anesthesia. This position helps improve venous return to the heart and can help alleviate hypotension by reducing aortocaval compression.
C. Applying oxygen via nasal cannula may be indicated if the client is experiencing respiratory distress, but it is not the primary intervention for hypotension.
D. Assisting the client to empty their bladder may be appropriate to relieve urinary retention but is not the priority intervention for hypotension.
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