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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The nurse should indeed consider the AP’s level of experience when making delegation decisions. This is because the level of experience can greatly influence the ability of the AP to perform the delegated tasks effectively and safely. An experienced AP may be more competent and confident in performing certain tasks compared to someone with less experience. Therefore, considering the AP’s level of experience is crucial in ensuring quality care for patients.
Choice B rationale
While it is true that APs can assist in providing client education about basic self-care, it is important to note that the scope of their teaching is limited. They can reinforce teaching done by the nurse but should not be the primary source of education, especially for complex care needs or new diagnoses. Therefore, this statement does not fully reflect effective delegation.
Choice C rationale
This statement is incorrect. Even when care is delegated to an AP, the nurse retains accountability for client outcomes. The nurse remains responsible for ensuring that the delegated tasks are completed correctly and safely. Therefore, this statement does not indicate effective delegation.
Choice D rationale
This statement is also incorrect. APs should not re-delegate tasks to another AP1. The nurse who delegated the task has assessed the competency and capabilities of the specific AP to whom the task was delegated. Re-delegation could lead to tasks being performed by someone who may not have the necessary skills or knowledge, potentially compromising patient safety.
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.
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