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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is choice B. “You are doing a great job.

It’s very difficult to support someone during this part of labor.” This response acknowledges the husband’s feelings and efforts, and provides reassurance and encouragement.

It also reflects the reality that active labor can be very intense and painful for the woman, and she may not want to be touched or talked to.

Choice A is wrong because it suggests that the husband is not needed or wanted, and may make him feel rejected or useless.

Choice C is wrong because it implies that the husband is not a good support person, and may hurt his self-esteem or damage his relationship with his wife.

Choice D is wrong because it focuses on the physical aspect of labor, rather than the emotional one.

It also assumes that the woman wants medication, which may not be the case.

A. Insulin amount needs will remain stable during the third trimester. B. Insulin amount needs will continue to increase throughout the second and third trimesters. C. Insulin amount needs will decrease during the third trimester. D. Insulin amount needs will remain stable for the rest of the second and during the third trimesters.

Correct Answer is B

Explanation

The correct answer is choice B. Insulin amount needs will continue to increase throughout the second and third trimesters.This is because gestational diabetes is a form of diabetes that develops during pregnancy, usually during the 2nd or 3rd trimester.It is caused by hormonal changes that interfere with the action of insulin, leading to high blood sugar levels.As the pregnancy progresses, the placenta produces more hormones that increase insulin resistance, so the mother needs more insulin to keep her blood sugar within normal range.

Choice A is wrong because insulin amount needs will not remain stable during the third trimester.They will increase as the placenta grows and produces more hormones that cause insulin resistance.

Choice C is wrong because insulin amount needs will not decrease during the third trimester.They will increase as the placenta grows and produces more hormones that cause insulin resistance.

Choice D is wrong because insulin amount needs will not remain stable for the rest of the second and during the third trimesters.They will increase as the pregnancy progresses and the placenta produces more hormones that increase insulin resistance.

Normal ranges for blood sugar during pregnancy are: fasting < 95 mg/dL, 1 hour after meal < 140 mg/dL, 2 hours after meal < 120 mg/dL.

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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?

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Naxlex Comprehensive Predictor Exams

nurse hears a client in active labor say to her husband, “Don’t touch me. Stay away.” The husband states, “I don’t know what to do. Everything I do is wrong.” Which response by the nurse would be the most supportive?

Correct Answer is B

Explanation

A patient who is 26 weeks pregnant has gestational diabetes and is to begin insulin management. When discussing the patient’s insulin needs, which information should the nurse include?

Correct Answer is B

Explanation

During the postpartal admission assessment, the nurse notes that a patient’s perineum appears edematous and ecchymotic. Based on this finding, which action should the nurse take?

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The physician prescribes prostaglandin (PGE2) gel for a patient being admitted for induction of labor. Which finding would best indicate that the prostaglandin gel is effective?

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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?