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
The correct answer is choice C. Dryness and flaking of the skin on the hands and feet.This is because a newborn with a gestational age of 42 weeks is considered post-mature and has lost the protective vernix caseosa that covers the skin of most newborns.The skin of a post-mature newborn is also more exposed to the amniotic fluid, which can cause it to peel and crack.
Choice A is wrong because sole creases that cover only the anterior one-third of the foot are characteristic of a preterm newborn, not a post-mature one.
Choice B is wrong because vernix caseosa is abundant in preterm newborns and decreases as gestational age increases.A post-mature newborn would have little or no vernix caseosa on the skin.
Choice D is wrong because a large amount of fine, downy hair (lanugo) on the back and shoulders is also typical of a preterm newborn, not a post-mature one.Lanugo usually disappears by 36 weeks of gestation.A post-mature newborn would have little or no lanugo on the body.
Correct Answer is C
Explanation
This is because the patient is experiencing supine hypotension syndrome, which occurs when the weight of the gravid uterus compresses the inferior vena cava and reduces venous return and cardiac output. Turning the patient onto her side will relieve the pressure and improve blood flow.
Choice A is wrong because taking the patient’s blood pressure will not address the cause of her symptoms and may delay appropriate intervention.
Choice B is wrong because breathing into her cupped hands will not improve her circulation and may increase her carbon dioxide levels.
Choice D is wrong because elevating the patient’s legs will not relieve the compression of the inferior vena cava and may worsen her condition.Normal blood pressure for a pregnant woman is 110/70 to 120/80 mmHg.Normal heart rate for a pregnant woman is 60 to 90 beats per minute.Normal respiratory rate for a pregnant woman is 16 to 24 breaths per minute.
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