A nurse is providing care for a patient who is in active labor and recognizes late decelerations on the fetal monitor.
The healthcare provider has been informed.
What is the nurse’s priority action?
Administer oxygen via face mask.
Elevate the patient’s legs.
Have the patient turn to a side-lying position.
Increase the infusion rate of the IV fluid.
The Correct Answer is C
Choice A rationale
Administering oxygen via face mask is a common intervention for many complications during labor. However, it is not the first-line intervention for late decelerations. Late decelerations are a sign of fetal distress, often due to uteroplacental insufficiency. While oxygen can help increase oxygenation to the fetus, it does not address the root cause of the problem.
Choice B rationale
Elevating the patient’s legs is not typically the priority action when late decelerations are noted. This action would not alleviate the cause of late decelerations.
Choice C rationale
Having the patient turn to a side-lying position is often the first intervention when late decelerations are noted. This position helps increase blood flow to the placenta, potentially alleviating uteroplacental insufficiency and improving fetal oxygenation.
Choice D rationale
Increasing the infusion rate of IV fluids is not the first-line intervention for late decelerations. While it may be part of the management plan, it is not the priority action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Tremors are a common side effect of terbutaline. Terbutaline is a medication used to inhibit uterine contractions in preterm labor. It is a beta-adrenergic agonist, and stimulation of the beta-adrenergic receptors can lead to side effects such as tremors.
Correct Answer is B
Explanation
Choice A rationale
While respiratory distress can be a serious condition in infants, it is not the leading cause of death among this age group. Other conditions, such as sudden infant death syndrome and complications from premature birth, are more common causes of death in infants.
Choice B rationale
Sudden Infant Death Syndrome (SIDS) is indeed a leading cause of death among infants. It is a significant health concern and a major cause of post-neonatal death. SIDS is the unexplained death, usually during sleep, of a seemingly healthy baby less than a year old.
Choice C rationale
Congenital anomalies can cause death in infants, but they are not the leading cause. Conditions such as SIDS and complications from premature birth are more common causes of infant death.
Choice D rationale
Low birth weight can contribute to health problems in infants and increase the risk of infant mortality. However, it is not the leading cause of death among infants. Conditions such as SIDS and complications from premature birth are more common causes.
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