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:

The client's statement, "I will check the identification badge of anyone who removes my baby from our room,” indicates an understanding of newborn safety. This statement shows the client's awareness of the importance of verifying the identity of anyone handling their baby before allowing them to be taken out of the room. Checking identification badges helps ensure that only authorized personnel, such as nurses or hospital staff, are allowed to handle the newborn, reducing the risk of unauthorized individuals taking the baby.

Choice B rationale:

This statement is incorrect and does not demonstrate an understanding of newborn safety. Including a photo of the baby along with public birth announcements to social media can compromise the baby's security and privacy. It may expose sensitive information about the baby's location and identity, making the baby vulnerable to potential risks.

Choice C rationale:

This statement is incorrect as it poses a safety risk to the newborn. Allowing the baby to sleep on the bed when the client is in the shower increases the risk of falls or suffocation. The baby should always be placed in a safe sleep environment, such as a crib or bassinet, to minimize the risk of accidents.

Choice D rationale:

This statement is incorrect and does not reflect an understanding of newborn safety. Nurses should not carry the baby in their arms to the nursery. Instead, they should use a crib or an infant carrier to transport the baby safely.

A. February 11th, 2019. B. February 27th, 2019. C. April 27th, 2019. D. August 11th, 2019.

Correct Answer is A

Explanation

Choice A rationale:

Naegele's Rule is used to estimate the expected delivery date (EDD) by adding 7 days and 9 months to the first day of the last menstrual period (LMP) In this case, May 4th, 2018, is the first day of the LMP. Adding 7 days brings us to May 11th, and then adding 9 months brings us to February 11th, 2019, which is the estimated delivery date.

Choice B rationale:

This option is incorrect because it adds 9 months to the LMP without accounting for the additional 7 days, resulting in an inaccurate EDD.

Choice C rationale:

This option is incorrect because it only adds 9 months to the LMP without considering the 7 days, leading to an inaccurate EDD.

Choice D rationale:

This option is incorrect because it adds 9 months to the LMP without considering the 7 days, resulting in an inaccurate EDD.

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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

A nurse is providing teaching about newborn safety to a client who is being admitted for induction of labor. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

A pregnant client's last menstrual period was May 4th, 2018. What is this client's estimated delivery date using Naegele's Rule?

Correct Answer is A

Explanation

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