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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

The rubella vaccine is a live vaccine, which means it contains a weakened version of the virus. Because the virus is still active, live vaccines are not safe for pregnant people. There is a small chance they may pass the virus to the baby. Therefore, it is recommended that adults of childbearing age should avoid getting pregnant for at least four weeks after receiving the MMR vaccine. This is to ensure the safety of both the mother and the baby.

Choice B rationale

This statement is incorrect. The rubella vaccine does not require additional shots after each baby with Rh-positive blood. The rubella vaccine is typically administered in childhood and provides long-term protection.

Choice C rationale

This statement is also incorrect. The rubella vaccine does not require additional shots in 1 month and again in 6 months. The vaccine provides long-term protection and does not typically require frequent boosters.

Choice D rationale

While it’s true that some vaccines can cause side effects such as fever and vomiting, these are not common side effects of the rubella vaccine. Therefore, this statement is not entirely accurate.

A. Hypoglycemia B. Neonatal abstinence syndrome C. Respiratory distress syndrome D. Neonatal jaundice .

Correct Answer is B

Explanation

Choice A rationale

Hypoglycemia, or low blood sugar, is a condition that can occur in newborns, especially those born to mothers with gestational diabetes. However, there is no information in the question indicating that the mother had gestational diabetes. Therefore, while hypoglycemia is a possible complication for newborns, it is not the most likely complication in this case based on the information provided.

Choice B rationale

Neonatal abstinence syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. NAS can occur when a pregnant woman takes drugs such as heroin, codeine, oxycodone (Oxycontin), methadone, or buprenorphine. These and other substances pass through the placenta that connects the baby to its mother in the womb and can cause the baby to become dependent on the drug. In this case, the mother’s urine toxicology screen was positive for cocaine and marijuana, both of which are illicit drugs. This puts the newborn at risk for developing NAS2.

Choice C rationale

Respiratory distress syndrome (RDS) is a breathing disorder that affects newborns. RDS is more common in premature babies because their lungs aren’t fully developed. However, the newborn in the question was born at 38 weeks gestation, which is considered full term. Therefore, while RDS is a possible complication for newborns, it is not the most likely complication in this case based on the information provided.

Choice D rationale

Neonatal jaundice is a condition that can occur in newborns due to high levels of bilirubin, a yellow pigment produced during normal breakdown of red blood cells. In older babies and adults, the liver processes bilirubin, which then passes from the body through the stool and urine. However, a newborn’s still-developing liver may not be mature enough to remove this bilirubin. While neonatal jaundice is a common condition, there is no information in the question indicating that the newborn is at risk for developing this complication.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client’s prenatal laboratory findings reveal no immunity to rubella.The health care provider orders the rubella vaccine.The nurse concludes that teaching about this medication is effective when the client states which of the following?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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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?