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.

Answer and Explanation

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.

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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.

A. Document the findings. B. Pause the oxytocin infusion. C. Raise the head of the patient’s bed 30 degrees. D. Notify the health care provider. E. Notify the health care provider.

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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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?

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Naxlex Comprehensive Predictor Exams

When assessing a newborn, which is the best method for the nurse to use to elicit the Moro reflex?

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

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