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 A rationale
Quickening is the sensation of fetal movement by the pregnant woman. It usually occurs between 16 and 20 weeks of gestation.
Choice B rationale
Hegar’s sign is a probable sign of pregnancy that is characterized by the compressibility and softening of the cervical isthmus, which is the portion of the cervix between the uterus and the vaginal portion of the cervix. This sign typically presents between the fourth and sixth week of pregnancy. Therefore, if the nurse identifies a probable sign indicating the softening of the lower uterine segment, it is likely that the nurse has observed Hegar’s sign.
Choice C rationale
Braxton Hicks contractions are intermittent uterine contractions that occur during pregnancy. They are not a sign of labor and do not lead to cervical dilation or effacement. Therefore, they would not indicate the softening of the lower uterine segment.
Choice D rationale
Ballottement is a technique of palpating a floating structure by bouncing it and feeling it rebound. In the context of pregnancy, it refers to the movement of the fetus when the uterus is tapped during a pelvic examination. This does not indicate the softening of the lower uterine segment.
Correct Answer is B
Explanation
Choice A rationale
Tarry stools are not a typical manifestation of cirrhosis. They are more commonly associated with gastrointestinal bleeding.
Choice B rationale
Spider angiomas are a common manifestation of cirrhosis. They are small, dilated blood vessels with a bright red center point and radiating branches, and they are often found on the face, neck, and chest.
Choice C rationale
Moist skin is not a typical manifestation of cirrhosis. Cirrhosis can cause various skin changes, but they typically include jaundice, pruritus, and palmar erythema.
Choice D rationale
Blood in the urine is not a typical manifestation of cirrhosis. It is more commonly associated with urinary tract infections, kidney stones, or bladder disorders.
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