A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?

Change the client's position.

Insert a scalp electrode.

Prepare for amnioinfusion.

Document benign decelerations.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The priority nursing action when the fetal heart rate shows a deceleration after the contraction has started, with the lowest point occurring after the peak of the contraction, is to change the client's position. This deceleration pattern is called "late decelerations,” and it is typically associated with uteroplacental insufficiency, which can be caused by maternal hypotension or impaired blood flow to the placenta. Changing the client's position, such as moving the client to their side or repositioning them, can alleviate pressure on the vena cava and improve blood flow to the placenta, thus potentially resolving or minimizing the late decelerations.

Choice B rationale:

Inserting a scalp electrode (Choice B) is not the priority action in this situation. While a scalp electrode may be used to monitor the fetal heart rate more accurately and continuously, it is not the initial intervention for addressing late decelerations.

Choice C rationale:

Preparing for amnioinfusion (Choice C) may be considered if there are variable decelerations (caused by cord compression) present, but it is not the priority intervention for late decelerations.

Choice D rationale:

Documenting benign decelerations (Choice D) is not appropriate in this scenario since late decelerations are not considered benign and require immediate action.

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Correct Answer is A

Explanation

Choice A rationale:

Before an amniocentesis, it is essential for the client to empty their bladder. A full bladder can interfere with the procedure, as it may obstruct the needle's entry into the uterus and increase the risk of accidental bladder puncture.

Choice B rationale:

Nothing by mouth (NPO) for 4 hours is not necessary for an amniocentesis. It is a relatively simple and quick procedure that does not require fasting.

Choice C rationale:

Ingesting 3 liters of water is not indicated before an amniocentesis. While some ultrasound examinations may require a full bladder, this is not the case for an amniocentesis.

Choice D rationale:

Nipple stimulation is not relevant or necessary before an amniocentesis. Nipple stimulation can trigger uterine contractions, which might be undesirable before the procedure, especially if the client is not in labor.

A. The fetal head is in the left occiput posterior position. B. The largest fetal diameter has passed through the pelvic outlet. C. The posterior fontanel is palpable. D. The lowermost portion of the fetus is at the level of the ischial spines.

Correct Answer is D

Explanation

Choice A rationale:

The clinical finding of 0 station does not provide information about the fetal head's position in the left occiput posterior position. Station refers to the level of the presenting part in relation to the ischial spines, not the position.

Choice B rationale:

The clinical finding of 0 station does not indicate that the largest fetal diameter has passed through the pelvic outlet. The station only tells us the level of the presenting part and does not provide information about the diameter passing through the pelvic outlet.

Choice C rationale:

The clinical finding of 0 station does not directly involve the palpability of the posterior fontanel. Station is determined based on the level of the presenting part in the birth canal.

Choice D rationale:

This is the correct interpretation of the clinical finding. 0 station means that the presenting part (usually the baby's head) is at the level of the ischial spines, which serves as a reference point during labor. As labor progresses and the baby moves further down the birth canal, the station becomes more negative (e.g., -1, -2) until delivery occurs.

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A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to an amniocentesis, what action by the client will need to be completed?

Correct Answer is A

Explanation

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

Correct Answer is D

Explanation

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