The nurse is assessing a patient in Labor with the findings in the chart: Fatal heart rate 135 with early decelerations. What action will the nurse implement?

Encourage the patient to ambulate intermittently and change positions.

Place the patient in the left lateral position and increase the oxytocin rate.

Administer oxygen 10 litters per minute via a non-rebreather mask.

Teach the patient to push when she feels the urge during contractions.

Answer and Explanation

The Correct Answer is A

Choice A reason: Encouraging the patient to ambulate intermittently and change positions can help alleviate early decelerations by improving uteroplacental blood flow and promoting fatal oxygenation. Movement and position changes can reduce compression on the umbilical cord and facilitate Labor progression.

Choice B reason: Placing the patient in the left lateral position can improve uteroplacental blood flow, but increasing the oxytocin rate is not indicated based on the current findings. Early decelerations are typically not a sign of Labor dystocia requiring oxytocin augmentation.

Choice C reason: Administering oxygen via a non-rebreather mask is generally reserved for situations where there is significant fatal distress or non-reassuring fatal heart rate patterns. Early decelerations are usually benign and do not necessitate supplemental oxygen.

Choice D reason: Teaching the patient to push when she feels the urge during contractions is appropriate during the second stage of Labor. However, the current findings with early decelerations do not indicate the need for this intervention at this time. The focus should be on monitoring and managing the fatal heart rate.

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Correct Answer is A

Explanation

Choice A reason: Providing patients with information regarding postpartum depression is crucial. Educating patients about the signs, symptoms, and treatment options for postpartum depression helps raise awareness and encourages early detection and intervention. Knowledge empowers patients and their families to seek help if needed.

Choice B reason: Encouraging patients to focus on positive aspects of pregnancy and birth is generally beneficial for emotional well-being, but it is not a specific strategy for addressing postpartum depression. Focusing solely on positive aspects may inadvertently dismiss the real and serious concerns of those experiencing postpartum depression.

Choice C reason: Consulting with the patient's spiritual advisor can be supportive, but it is not a primary strategy for addressing postpartum depression. While spiritual support can be a valuable component of holistic care, it should complement, not replace, medical and psychological interventions.

Choice D reason: Avoiding the assessment of suicidal thoughts to not upset the patient is dangerous and counterproductive. It is essential to assess for suicidal ideation in patients with postpartum depression to ensure their safety and provide appropriate interventions. Open and compassionate discussions about mental health are critical in addressing postpartum depression effectively.

A. Call the healthcare provider. B. Provide supplemental oxygen. C. Stop the infusion. D. Encourage oral intake.

Correct Answer is C

Explanation

Choice A reason: Calling the healthcare provider is important, but the immediate priority is to stop the infusion to prevent further fluid overload, which is likely causing the bilateral crackles.

Choice B reason: Providing supplemental oxygen can be necessary if the child is showing signs of respiratory distress, but it is not the primary action to address the underlying issue of fluid overload.

Choice C reason: Stopping the infusion is the most critical action to prevent further fluid overload, which is causing the bilateral crackles. This immediate intervention can help prevent worsening pulmonary enema and respiratory complications.

Choice D reason: Encouraging oral intake is not appropriate in this scenario as the child is already receiving intravenous fluids for severe dehydration. Additionally, with signs of fluid overload, further fluid intake should be carefully managed.

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The nurse is assessing a patient in Labor with the findings in the chart: Fatal heart rate 135 with early decelerations. What action will the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching the student nurse about postpartum depression. Which strategy will the nurse include in the teaching?

Correct Answer is A

Explanation

The nurse is caring for a child who is diagnosed with severe dehydration and is being treated with intravenous fluids. The nurse notes bilateral crackles on lung auscultation. Which actions will the nurse prioritize?

Correct Answer is C

Explanation

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