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 D
Explanation
The correct answer is choice D. Wear a supportive bra.This will help suppress lactation and reduce the discomfort of engorgement.
The other choices are wrong because:
• Choice A. Manually express colostrum as necessary.This will stimulate milk production and prolong engorgement.
• Choice B. Apply hot compresses to the breasts.This will increase blood flow and swelling in the breasts and worsen engorgement.
• Choice C. Massage the breast tissue surrounding the areola.This will also stimulate milk production and prolong engorgement.
Normal ranges for breast engorgement are not applicable as it is a subjective experience that varies among women.However, some signs of engorgement include firm, tender, swollen breasts, flat or inverted nipples, and low-grade fever.Engorgement usually resolves within 24 to 36 hours after it begins.
Correct Answer is A
Explanation
The correct answer is choice A and it indicates fetal distress because it is a sign oflate deceleration.Late decelerations are due touteroplacental insufficiencyas the result of decreased blood flow and oxygen to the fetus during the uterine contractions.This causeshypoxemiaand can lead to fetal acidosis and neurological damage.
Choice B is wrong because it indicates anormal variabilityin the fetal heart rate, which reflects a healthy autonomic nervous system.A normal fetal heart rate is 120-160 beats per minute.
Choice C is wrong because it indicates anearly accelerationin the fetal heart rate, which is a benign finding that may occur with fetal movement or stimulation.
Choice D is wrong because it indicates anearly decelerationin the fetal heart rate, which is a normal response to fetal head compression during contractions.
It does not indicate fetal distress.
Normal ranges for fetal heart rate patterns are:
• Baseline: 120-160 beats per minute
• Variability: 6-25 beats per minute
• Accelerations: at least 15 beats per minute above baseline for at least 15 seconds
• Decelerations: none or early (mirror contractions)
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