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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Restricting protein intake to less than 40 g/day is not appropriate for a client with preeclampsia with severe features. While protein restriction might be advised in some cases of preeclampsia, it is not a priority in severe cases where the focus is on managing potential complications.
Choice B rationale:
Initiating seizure precautions is essential in managing a client with preeclampsia with severe features. Preeclampsia can lead to eclampsia, a condition characterized by seizures. Seizure precautions involve implementing measures to prevent injury during a seizure, such as padding the side rails of the bed, ensuring a clear environment, and having emergency equipment readily available.
Choice C rationale:
Initiating an infusion of 0.9% sodium chloride at 150 ml/hr is not directly related to managing preeclampsia with severe features. Although intravenous fluids may be necessary in some cases, the priority in this situation is to prevent and manage potential seizures.
Choice D rationale:
Encouraging the client to ambulate twice per day is not appropriate for a client with preeclampsia with severe features. Bed rest is often recommended in severe cases to reduce stress on the cardiovascular system and decrease the risk of complications.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should discontinue the oxytocin infusion if the client's contraction frequency is every 3 minutes. Frequent contractions may lead to uterine hyperstimulation, which can reduce fetal blood flow and oxygenation, potentially causing fetal distress. Normal contraction frequency during labor is typically every 2 to 5 minutes.
Choice B rationale:
Contraction duration of 100 seconds is not an indication to discontinue the oxytocin infusion. The duration of contractions can vary during labor, and 100 seconds is within the normal range of contraction duration, which is usually 45 to 90 seconds.
Choice C rationale:
Fetal heart rate with moderate variability is not an indication to discontinue the oxytocin infusion. Moderate variability in fetal heart rate is a reassuring sign, indicating a healthy fetal response to labor. It shows that the fetus is tolerating the contractions well and is not experiencing fetal distress.
Choice D rationale:
A fetal heart rate of 118/min is not an indication to discontinue the oxytocin infusion. The normal fetal heart rate range is typically between 110 to 160 beats per minute, and a heart rate of 118/min falls within this normal range. However, if the fetal heart rate deviates significantly from the normal range or shows signs of distress, further assessment and intervention are required.
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