A nurse is performing a nonstress test for a client who is at 38 weeks of gestation. The fetal monitor tracing reveals a series of late decelerations.
Which of the following interventions should the nurse implement first?
Place the client in a lateral position.
Administer lactated Ringer's via IV bolus.
Prepare the client for a cesarean birth.
Elevate the client's legs.
The Correct Answer is A
Choice A rationale
Late decelerations indicate uteroplacental insufficiency, meaning reduced blood flow and oxygen to the fetus. Placing the client in a lateral position (left or right side) can alleviate pressure on the vena cava, improving venous return to the heart, thus increasing cardiac output and uteroplacental perfusion. This is the least invasive initial intervention.
Choice B rationale
While intravenous fluid administration may be indicated in some cases to improve maternal hydration and placental perfusion, repositioning the client is a more immediate and less invasive intervention to address uteroplacental insufficiency by optimizing maternal circulation and oxygen delivery to the fetus.
Choice C rationale
Preparing for a cesarean birth is a significant intervention reserved for persistent or severe fetal distress that does not respond to less invasive measures. Although late decelerations are concerning, immediate surgical intervention is not the first step without attempting to optimize fetal well-being through maternal repositioning.
Choice D rationale
Elevating the client's legs might slightly increase venous return, but it is not the primary intervention for late decelerations. The lateral position is more effective in relieving aortocaval compression, directly addressing the underlying issue of reduced placental blood flow, and is the established first-line intervention.
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Correct Answer is B
Explanation
Choice A rationale
Administering oxygen via nasal cannula at 2 L/min might marginally increase fetal oxygenation, but it does not address the primary issue of hypotension causing decreased placental perfusion. The fundamental problem is reduced blood flow to the placenta, necessitating interventions that increase maternal circulating volume and blood pressure to improve perfusion.
Choice B rationale
Administering a lactated Ringer's 500 mL bolus directly addresses hypotension by expanding the maternal intravascular volume. This increased circulating volume raises blood pressure, thereby improving placental perfusion and oxygen delivery to the fetus. Lactated Ringer's is an isotonic solution, effective for rapid volume expansion.
Choice C rationale
Placing the client in a knee-chest position is typically used to alleviate cord compression or prolapse by shifting the fetus, not for treating hypotension. This position can actually worsen hypotension by trapping blood in the lower extremities and reducing venous return to the heart, further compromising placental blood flow.
Choice D rationale
Monitoring the client's blood pressure every 30 minutes is a crucial assessment but is not an immediate intervention for acute hypotension with decreased placental perfusion. While ongoing monitoring is essential, immediate actions are required to correct the underlying cause of hypotension and restore adequate blood flow to the placenta.
Correct Answer is C
Explanation
Choice A rationale
The critical congenital heart disease (CCHD) screening is typically performed when the newborn is between 24 and 48 hours of age, or just prior to discharge if that occurs earlier. Performing the test too early, such as between 6 and 12 hours, might yield false negative results due to the persistence of transitional circulation.
Choice B rationale
The results of the CCHD screening are typically available immediately, or within a few minutes, as it involves pulse oximetry readings. There is no waiting period of 1 to 2 weeks for the results, allowing for prompt identification and management of potential cardiac defects, preventing delays in care.
Choice C rationale
The CCHD screening specifically compares the oxygen saturation in the newborn's right hand (pre-ductal) and either foot (post-ductal). A significant difference between these two readings can indicate a shunt or obstruction within the heart or great vessels, suggesting a potential critical congenital heart defect.
Choice D rationale
Collecting a blood sample from the newborn's heel is the procedure for the newborn metabolic screening, which screens for various genetic and metabolic disorders, not the critical congenital heart disease screening. The CCHD screening is a non-invasive test performed using pulse oximetry.
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