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 B

Explanation

Choice A rationale:

High calcium levels are not typically associated with the use of anastrozole, an aromatase inhibitor. Aromatase inhibitors work by blocking the conversion of androgens to estrogens, and they do not directly impact calcium levels.

Choice B rationale:

Muscle and joint pain is a common side effect of aromatase inhibitors like anastrozole. These medications can lead to musculoskeletal discomfort, including joint stiffness and pain, which the nurse should inform the client about to ensure she is aware of potential adverse effects.

Choice C rationale:

Heart failure is not a known side effect of anastrozole. The drug's primary concern is its impact on the musculoskeletal system, particularly causing joint and muscle pain.

Choice D rationale:

Polyphagia, which refers to excessive hunger and increased food intake, is not associated with the use of anastrozole. This choice is unrelated to the side effects of the medication and can be ruled out.

A. "I will notify my provider if I experience chest pain, shortness of breath, or leg pain.” B. "I will use an alternative form of birth control if I miss three pills.” C. "If I miss three pills, I will double up each day until back on schedule.” D. "I will have to have follow-up appointments with my provider while taking this medication.”

Correct Answer is C

Explanation

Choice A rationale:

This statement indicates that the client understands the potential side effects of oral contraception and the importance of reporting them promptly to their healthcare provider. Chest pain, shortness of breath, or leg pain can be indicative of serious complications, such as blood clots, which can occur with oral contraceptive use.

Choice B rationale:

This statement demonstrates the client's understanding of what to do if they miss three pills. Using an alternative form of birth control is a responsible action to prevent unintended pregnancies, as missing multiple pills can decrease contraceptive effectiveness.

Choice C rationale:

This statement reveals a misunderstanding of the appropriate action to take if the client misses three pills. Instead of doubling up, the client should be instructed to take the missed pill as soon as they remember and continue taking the pills as usual. Doubling up can increase the risk of side effects and won't necessarily prevent pregnancy.

Choice D rationale:

This statement indicates that the client comprehends the need for follow-up appointments while on oral contraception. Regular follow-ups are essential to monitor the client's health, address any concerns, and ensure the effectiveness of the chosen contraceptive method.

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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 caring for a postmenopausal client prescribed the aromatase inhibitor, anastrozole, for the treatment of breast cancer. Which of the following should the nurse tell the client she may experience?

Correct Answer is B

Explanation

A nurse has provided education to a client who has been prescribed oral contraception. Which of the following client statements indicates a need for further education?

Correct Answer is C

Explanation

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