A patient’s labor is induced using an intravenous infusion of 1,000 mL Ringer’s lactate with 10 units of oxytocin.
Two hours later, the nurse notes a pattern of late fetal heart rate decelerations detected on the fetal monitor.Which action is essential for the nurse to take first?
Document the findings.
Pause the oxytocin infusion.
Raise the head of the patient’s bed 30 degrees.
Notify the health care provider.
Notify the health care provider.
The Correct Answer is B
This is because late fetal heart rate decelerations are a sign of uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen and nutrients to the fetus. Oxytocin can cause uterine tachysystole, which is excessive and frequent contractions that reduce blood flow to the placenta.Therefore, stopping the oxytocin infusion can help improve placental perfusion and fetal oxygenation.
Choice A is wrong because documenting the findings is not a priority action in this situation.
The nurse should first intervene to address the cause of late decelerations and then document the actions and outcomes.
Choice C is wrong because raising the head of the patient’s bed 30 degrees does not directly affect the placental blood flow or fetal oxygenation.
It may help with maternal comfort and breathing, but it is not an essential action for late decelerations.
Choice D is wrong because notifying the health care provider is not the first action to take.The nurse should first attempt to correct the cause of late decelerations by pausing the oxytocin infusion and then notify the health care provider if there is no improvement or if there are other signs of fetal distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A.Making a loud sound within close range of the newborn will elicit the Moro reflex, which is an involuntary protective motor response against abrupt disruption of body balance or extremely sudden stimulation.The Moro reflex involves three distinct components: spreading out the arms (abduction), pulling the arms in (adduction), and crying (usually).
Choice B is wrong because firmly stroking the soles of the newborn’s feet with a thumb nail will elicit the Babinski reflex, which is a normal response in infants that involves fanning out and curling of the toes.
Choice C is wrong because using the newborn’s hands to raise the baby from a supine position without supporting the head will elicit the traction response, which is a normal response in infants that involves flexion of the elbows and shoulders.
Choice D is wrong because holding the newborn in an upright position so that the infant’s feet touch a cool, flat surface will elicit the stepping reflex, which is a normal response in infants that involves alternating steps with each foot.
Correct Answer is A
Explanation
The correct answer is choice A: To minimize the patient’s oxygen needs.
A neutral thermal environment is an environment in which a neonate maintains a normal body temperature while minimizing energy expenditure and oxygen consumption.This is important for the wellbeing of neonates, especially those who are preterm or have respiratory insufficiency.
Choice B is wrong because the conversion of glucose to lactic acid is not a desired outcome of a neutral thermal environment.This conversion occurs when there is inadequate oxygen supply to the tissues, resulting in anaerobic metabolism and metabolic acidosis.
Choice C is wrong because the absorption of surfactant from the alveoli is not affected by a neutral thermal environment.
Surfactant is a substance that reduces surface tension and prevents alveolar collapse.It is produced by type II alveolar cells and secreted into the alveoli.
Choice D is wrong because the metabolism of brown fat stores is not a desired outcome of a neutral thermal environment.
Brown fat is a specialized tissue that generates heat by nonshivering thermogenesis in response to cold stress.
It is located in the nape of the neck, between the scapulae, and around the kidneys and adrenals.It increases the metabolic rate and oxygen consumption of neonates.
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