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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Current guidelines recommend that women aged 21 to 29 have a Pap test every three years, and those aged 30 to 65 can either have a Pap test every three years or a Pap plus HPV (human papillomavirus) test every five years. After age 65, and with a history of normal results, Pap tests may be discontinued.
Choice B rationale:
The nurse should not include choice B, "Pap tests are discontinued following removal of the ovaries,” in the teaching. The presence or absence of ovaries does not affect the need for Pap testing. The Pap test is primarily used to screen for cervical cancer, and its necessity is determined based on age and previous screening results, not on ovarian status.
Choice C rationale:
Patients are advised to avoid sexual intercourse, douching, or using vaginal medications for 24 hours before the test to ensure accurate results.
Choice D rationale:
The nurse should not include choice D, "Viral infections can be detected by a Pap test,” in the teaching. The Pap test is not designed to detect viral infections. Instead, it is used to detect abnormal cervical cells, which may indicate pre-cancerous or cancerous changes.
Correct Answer is A
Explanation
Choice A rationale:
Assisting the client to void is a priority intervention in this situation. A full bladder can displace the uterus and prevent it from contracting effectively, leading to a boggy and high- positioned fundus. After the client empties her bladder, the nurse should reassess the fundus to ensure it has descended to its appropriate location, which is usually at or just below the level of the umbilicus.
Choice B rationale:
Documenting the findings as within normal limits is incorrect because a firm, displaced fundus that is 3 cm above the umbilicus is not considered normal. This finding indicates that the uterus is not contracting adequately, and the nurse should take appropriate actions to address the issue.
Choice C rationale:
Gently massaging the client's fundus is not the correct intervention in this case. Massaging a firm fundus could cause uterine irritation and should be avoided. Instead, the nurse should encourage the client to empty her bladder, which often helps the uterus contract and descend to its proper position.
Choice D rationale:
Encouraging the client to ambulate may be helpful in some cases to promote uterine contractions and involution. However, in this situation, the priority is to address the full bladder, as it is a common cause of a displaced and high fundus shortly after delivery.
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