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 D
Explanation
Choice A rationale:
This statement is incorrect. The client should receive Rh(D) immune globulin (RhoGAM) if they are Rh-negative and their partner's Rh status is unknown or Rh-positive. This prevents the development of Rh antibodies in the mother's blood, which could be harmful in future pregnancies if the baby is Rh-positive.
Choice B rationale:
This statement is incorrect. Rh(D) immune globulin is administered to an Rh-negative mother within 72 hours after delivery if the baby is Rh-positive. This is done to prevent the mother from developing Rh antibodies that could affect subsequent pregnancies.
Choice C rationale:
This statement is incorrect. There is no restriction on receiving other immunizations after receiving Rh(D) immune globulin. The shot only protects against Rh incompatibility and does not interfere with other immunizations.
Choice D rationale:
This statement is correct. Rh(D) immune globulin can be given after birth to an Rh-negative mother with an Rh-positive baby. This helps protect the mother's future pregnancies from the potential harmful effects of Rh incompatibility.
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.
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