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 C
Explanation
Choice A rationale
Restricting outdoor activity to 1 hour per day is not necessary for patients with sickle cell anemia. While strenuous exercise and overexertion should be avoided, regular moderate exercise is beneficial and helps to promote good overall health.
Choice B rationale
Applying cold compresses when the child expresses pain is not recommended. Cold can lead to vasoconstriction, which can trigger a sickle cell crisis. Instead, warm compresses are often used to help increase circulation and reduce pain.
Choice C rationale
Drinking fluids multiple times every day is crucial. Hydration helps to keep the blood diluted and reduces the chances of a sickle cell crisis. Dehydration can increase the risk of a sickle cell crisis.
Choice D rationale
Monitoring temperature daily is not specifically required for patients with sickle cell anemia. However, any signs of infection, such as fever, should be reported to a healthcare provider immediately, as infection can trigger a sickle cell crisis.
Correct Answer is B
Explanation
Choice B rationale
When a couple is found to be carriers of an autosomal-recessive disorder, one of the actions the nurse can take is to discuss options with the couple, including amniocentesis to determine if their fetus is affected. This procedure can provide definitive information about the genetic status of the fetus, allowing the couple to make informed decisions about the pregnancy.
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