The fetal monitor indicates that a patient is having contractions every three to four minutes with late fetal decelerations.Which action should the nurse take first?
Notify the health care provider.
Position the patient in a left lateral position.
Increase the patient’s intravenous rate.
Provide the patient with oxygen via a face mask.
The Correct Answer is B
The correct answer is choice B. Position the patient in a left lateral position. This is because late fetal decelerations indicate uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen to the fetus. By positioning the patient on her left side, the blood flow to the placenta and the fetus is improved.
Choice A is wrong because notifying the health care provider is not the first action that the nurse should take. The nurse should first intervene to correct the cause of fetal distress and then inform the provider.
Choice C is wrong because increasing the patient’s intravenous rate may not help with uteroplacental insufficiency. It may also cause fluid overload or pulmonary edema in the patient.
Choice D is wrong because providing the patient with oxygen via a face mask is not the most effective way to increase fetal oxygenation. Oxygen therapy may be used as an adjunct to other interventions, but it is not sufficient by itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is because a normal fetal heart rate is between 110 and 160 beats per minute, and the range of 136 to 143 indicates that the fetus is well-oxygenated and not experiencing hypoxia or acidosis. The nurse should reassure the patient and explain that fetal movement may decrease during labor due to the pressure of the contractions on the uterus and the fetus.
Choice A is wrong because asking the patient about alcohol consumption is irrelevant and insensitive.
Alcohol can affect fetal development and growth, but it does not directly affect fetal movement or heart rate.
Choice B is wrong because bloody vaginal discharge, or bloody show, is a normal sign of cervical dilation and effacement during labor.
It does not indicate fetal distress or placental abruption.
Choice D is wrong because explaining the relationship between anxiety and fetal movement does not address the patient’s concern or provide any factual information.
Anxiety can affect maternal perception of fetal movement, but it does not cause fetal movement to decrease.
The nurse should validate the patient’s feelings and provide factual reassurance.
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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