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:

This is the correct choice. The American Academy of Pediatrics (AAP) recommends keeping children in a rear-facing car seat until they reach the age of 2 or until they reach the maximum weight and height allowed by the car seat's manufacturer. This is because rear- facing seats provide better support for a baby's head, neck, and spine during a crash, reducing the risk of injury.

Choice B rationale:

Placing the retainer clip over the upper part of the baby's abdomen is incorrect and potentially dangerous. The retainer clip should be positioned at armpit level to secure the harness straps properly.

Choice C rationale:

Placing the baby in the car seat at a 90-degree angle is not necessary. The car seat should be installed according to the manufacturer's instructions, and the angle will vary based on the specific car seat model.

Choice D rationale:

Placing the shoulder harness straps in the slots an inch above the baby's shoulders is incorrect. The straps should be positioned at or below the baby's shoulders for rear-facing car seats and at or above the shoulders for forward-facing seats.

A. Decrease fiber intake. B. Avoid Kegel exercises. C. Restrict fluid intake to 1 liter per day. D. Reduce intake of caffeinated and carbonated beverages.

Correct Answer is D

Explanation

Choice A rationale:

Decreasing fiber intake is not a recommended action for urinary incontinence. Fiber intake is related to bowel health and does not directly affect urinary incontinence.

Choice B rationale:

Avoiding Kegel exercises is not recommended for urinary incontinence. Kegel exercises are beneficial for strengthening the pelvic floor muscles, which can help improve urinary continence.

Choice C rationale:

Restricting fluid intake to 1 liter per day is not advisable for urinary incontinence. Adequate hydration is essential for overall health, and limiting fluid intake can lead to dehydration and other health issues.

Choice D rationale:

Reducing intake of caffeinated and carbonated beverages is a helpful recommendation for a client experiencing urinary incontinence. Caffeine and carbonation can irritate the bladder and worsen incontinence symptoms.

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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 teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing urinary incontinence. Which of the following recommendations should the nurse include in the teaching plan for this client?

Correct Answer is D

Explanation

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