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 B
Explanation
Choice B rationale
Hypertension is the most common risk factor for placental abruption. Hypertension can cause constriction of the blood vessels, including those in the placenta, which can lead to detachment of the placenta from the uterine wall.
Correct Answer is A
Explanation
Choice A rationale
If a client reports feeling “down” and sad, having no energy, and wanting to cry, these could be signs of postpartum depression. It’s crucial to assess whether the client has considered harming her newborn, as this could indicate a severe form of postpartum depression that requires immediate intervention.
Choice B rationale
While anticipating a prescription for an antidepressant might be part of the treatment plan for postpartum depression, it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.
Choice C rationale
Assisting the family to identify prior use of positive coping skills in family crises could be helpful, but it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.
Choice D rationale
Reinforcing postpartum and newborn care discharge teaching is important, but it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.
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