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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. She works as a part-time oncology nurse.This is because oncology nurses are exposed toteratogenic agents, which are substances that can cause abnormalities in an exposed fetus.Teratogenic agents can cross the placenta and alter fetal morphology or function.Examples of teratogenic agents are lead, methyl mercury, polychlorinated biphenyls, lithium, vitamin K antagonists, tobacco, rubella, cytomegalovirus, ionizing agents, hyperthermia, diabetes, and some drugs.
Choice A is wrong because living with two dogs at home does not pose a high risk for exposure to teratogenic agents.Dogs can be beneficial for pregnant women as they provide companionship and exercise.
Choice C is wrong because being a lacto-ova vegetarian does not pose a high risk for exposure to teratogenic agents.Lacto-ova vegetarians can get adequate nutrition from plant-based foods, dairy products, and eggs.
Choice D is wrong because commuting to work on a train does not pose a high risk for exposure to teratogenic agents.Trains are a safe and convenient mode of transportation for pregnant women.
Correct Answer is B
Explanation
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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