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. Maintaining the infants’ airways is the nurse’s priority when caring for a set of twins delivered by cesarean delivery.This is because twins are more likely to be born early and need special care after birth than single babies.They may have breathing difficulties or low oxygen levels and require oxygen therapy or ventilation.

The nurse should assess the infants’ respiratory status and intervene as needed.

Choice B is wrong because keeping the infants in a warm, draft-free environment is important but not as urgent as ensuring their airways are clear and they are breathing well.Premature twins may have trouble regulating their body temperature and need to be kept warm, but this can be done after their airways are secured.

Choice C is wrong because placing identification bands on the infants is a standard procedure but not a priority.

The nurse should make sure the infants are correctly identified and matched with their mother, but this can be done after their vital signs are stable.

Choice D is wrong because monitoring the infants’ vital signs is also important but not as urgent as maintaining their airways.

The nurse should check the infants’ heart rate, blood pressure, temperature and blood sugar levels regularly, but this can be done after their respiratory status is assessed and managed.

Normal ranges for vital signs in newborns are:

• Heart rate: 100 to 160 beats per minute

• Blood pressure: 50 to 75 mm Hg systolic and 30 to 45 mm Hg diastolic

• Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)

• Blood sugar: 40 to 80 mg/dL

A. “To determine fetal lung maturity.”. B. “To assess the degree of fetal renal function.”. C. “To test the amniotic fluid glucose level.”. D. “To detect the presence of fetal congenital anomalies.”.

Correct Answer is A

Explanation

Choice A reason:
At 37 weeks, especially in gestational diabetes, fetal lungs may still be immature. Amniocentesis checks lung maturity to ensure the baby can breathe effectively if early delivery is needed due to fetal compromise.

Choice B reason:
Fetal renal function is not typically assessed through amniocentesis at term. Kidney function is monitored via ultrasound, not by analyzing amniotic fluid at 37 weeks.

Choice C reason:
Amniotic fluid glucose levels are not used to manage gestational diabetes. Maternal blood glucose is the standard for monitoring and treatment.

Choice D reason:
Congenital anomalies are usually detected earlier in pregnancy. By 37 weeks, the focus of amniocentesis is on delivery planning, not anomaly detection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which measure should be the nurse’s priority when caring for a set of twins delivered by cesarean delivery?

Correct Answer is A

Explanation

A nurse is caring for a client who has gestational diabetes and is scheduled for an amniocentesis at 37 weeks of gestation due to suspected fetal compromise. What is the nurse’s best response to the client’s question as to why the amniocentesis test is being done?

Correct Answer is A

Explanation

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